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Brown MC, Tickle K, Woods K, Sidonio RF. Adequate menstrual suppression in adolescents with inherited bleeding disorders often requires multiple treatment changes: Retrospective cohort study of a multidisciplinary clinic. Pediatr Blood Cancer 2024; 71:e30944. [PMID: 38462776 DOI: 10.1002/pbc.30944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 01/25/2024] [Accepted: 02/22/2024] [Indexed: 03/12/2024]
Abstract
Heavy menstrual bleeding (HMB) is often the presenting symptom for females with inherited bleeding disorders (IBD). Multidisciplinary clinics leverage the expertise of hematologists and women's health specialists. This study characterizes the complexity of HMB management for adolescents with IBDs from a large multidisciplinary clinic. Adolescents often required multiple different menstrual suppression treatments, with only about 20% achieving acceptable suppression with their first treatment. Adolescents switched therapy most often for uncontrolled bleeding, followed by adverse effects, and patient preference. Given the difficulty in achieving adequate menstrual suppression, multidisciplinary clinics offer necessary expertise in accomplishing bleeding control with minimal adverse effects.
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Affiliation(s)
- Megan C Brown
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
- Aflac Cancer and Blood Disorders at Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Kelly Tickle
- Aflac Cancer and Blood Disorders at Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Kalinda Woods
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Robert F Sidonio
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
- Aflac Cancer and Blood Disorders at Children's Healthcare of Atlanta, Atlanta, Georgia, USA
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Venturella R, Lukes AS, Wu R, McLean R, Rakov VG, Al-Hendy A. Quality of life improvements in women with uterine fibroids treated with relugolix combination therapy during the LIBERTY long-term extension study: A descriptive subgroup analysis in women with anemia at baseline. Int J Gynaecol Obstet 2024; 165:431-441. [PMID: 38576220 DOI: 10.1002/ijgo.15505] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 03/13/2024] [Accepted: 03/13/2024] [Indexed: 04/06/2024]
Abstract
OBJECTIVE To investigate the effects of 52 weeks of treatment with relugolix combination therapy (relugolix 40 mg, estradiol 1 mg, norethindrone acetate 0.5 mg) on symptoms of uterine fibroids (UF) and quality of life (QoL) in women with heavy menstrual bleeding associated with UF and anemia (hemoglobin ≤10.5 g/dL) at baseline. METHODS This post hoc analysis included women from the LIBERTY long-term extension study with anemia (hemoglobin concentration ≤10.5 g/dL) at pivotal study baseline and documented hemoglobin values at week 52 (anemia-evaluable population). Treatment responders: women achieving a menstrual blood loss volume of <80 mL and a ≥50% reduction over the last 35 days of treatment. Anemia responders were women achieving a hemoglobin increase of >2 g/dL from baseline to week 52. Least squares (LS) mean changes from baseline in uterine fibroid symptom (UFS)-QoL symptom severity, fatigue, and health-related QoL total (HR-QoL) and (sub)scale scores were calculated. RESULTS In total, 115 women were included in the anemia-evaluable population. Of 39 anemia-evaluable women who received continuous treatment with relugolix combination therapy for 52 weeks, 34 (87.2%) met treatment responder criteria and 23 (59.0%) were anemia responders. LS mean hemoglobin concentration increased by 29.4% at week 52. LS mean UFS-QoL symptom severity and fatigue scores decreased by 38.5 and 31.9 points, respectively, and HR-QoL total score increased by 41.6 points. CONCLUSION In women with UF and a high disease burden due to anemia, relugolix combination therapy substantially improved hemoglobin levels, decreased distress due to symptoms, especially fatigue, over 52 weeks.
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Affiliation(s)
- Roberta Venturella
- Department of Experimental and Clinical Medicine, Magna Græcia University of Catanzaro, Catanzaro, Italy
| | - Andrea S Lukes
- Carolina Women's Research and Wellness Center, Durham, North Carolina, USA
| | - Rui Wu
- Data Science, Sumitomo Pharma America, Inc., Cambridge, Massachusetts, USA
| | - Rachel McLean
- Clinical Research, Sumitomo Pharma America, Inc., Cambridge, Massachusetts, USA
| | | | - Ayman Al-Hendy
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, Illinois, USA
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Schmiedl J, Castaman G. Awareness of von Willebrand disease among gynecologists: Investigating the referral of women with heavy menstrual bleeding to hematologists. Int J Gynaecol Obstet 2024. [PMID: 38607272 DOI: 10.1002/ijgo.15546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 03/13/2024] [Accepted: 04/02/2024] [Indexed: 04/13/2024]
Abstract
SynopsisAwareness of bleeding disorders, including von Willebrand disease, as a cause of heavy menstrual bleeding is low among gynecologists/obstetricians, potentially delaying diagnosis and appropriate treatment.
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Affiliation(s)
- Jolana Schmiedl
- Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
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Oliveira JA, Eskandar K, Chagas J, do Nascimento LLDO, Ribeiro DD, Rocha ALL, de Oliveira FR. Heavy menstrual bleeding in women with inherited bleeding disorders in use of LNG-IUS: A systematic review and single-arm meta-analysis. Contraception 2024:110450. [PMID: 38614274 DOI: 10.1016/j.contraception.2024.110450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 04/08/2024] [Indexed: 04/15/2024]
Abstract
PURPOSE Inherited bleeding disorders may cause heavy menstrual bleeding in women, impacting quality of life and impairing daily and social activities. The levonorgestrel-releasing intrauterine system is a potential treatment for these women, which might reduce menstrual blood loss. METHODS We performed a systematic review and single-arm meta-analysis to examine the levonorgestrel-releasing intrauterine system in women with inherited bleeding disorders and heavy menstrual bleeding. RESULTS A systematic search on PubMed, Embase and Cochrane yielded 583 results, of which six observational studies (n= 156) met inclusion criteria. Levonorgestrel-releasing intrauterine system use in patients with inherited bleeding disorders and heavy menstrual bleeding was associated with amenorrhea in 60% of patients and a significant increase of 1.40 g/dL in hemoglobin and of 19.75 ng/mL in ferritin levels when comparing post- and pre-treatment levels. The post-treatment mean hemoglobin was 13.32 g/dL and the mean ferritin was 43.22 ng/dL. The rate of intrauterine device expulsion or removal due to mal position was low (13%), as was the need for intrauterine device removal due to lack of efficacy (14%). CONCLUSION The levonorgestrel-releasing intrauterine system may improve bleeding patterns and quality of life in patients with inherited bleeding disorders and heavy menstrual bleeding.
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Affiliation(s)
| | | | - Júnea Chagas
- Federal University of Minas Gerais, Belo Horizonte, Brazil
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Hermans C, Johnsen JM, Curry N. Women and girls with inherited bleeding disorders: Focus on haemophilia carriers and heavy menstrual bleeding. Haemophilia 2024; 30 Suppl 3:45-51. [PMID: 38532560 DOI: 10.1111/hae.14983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 02/15/2024] [Accepted: 02/23/2024] [Indexed: 03/28/2024]
Abstract
Raising awareness and improving recognition, accurate classification, and enhanced access to new treatments represent current key challenges for carriers of haemophilia. Women and girls carrying genes for haemophilia often experience significant bleeding and/or low factor levels. The bleeding associated with female haemophilia is frequently overlooked, has a weak correlation with factor levels, and manifests differently than in males, with heavy menstrual bleeding being a predominant symptom. Recent changes in terminology now allow the diagnosis of haemophilia in females with low factor levels and differentiate between symptomatic and asymptomatic carriers of the gene. Observations from real-world experiences and limited clinical trial data have highlighted the positive impact of various new haemophilia treatments for women and girls with clotting factor deficiencies. There is an urgent need for initiatives that increase their access to these treatments and encourage well-designed clinical trials focusing on female-specific outcomes. In women with inherited bleeding disorders, early recognition and optimal management of heavy menstrual bleeding are crucial. However, treatment options and guidance from high-quality clinical trials are currently insufficient. Menstrual health assessment should be a regular part of monitoring women and girls with inherited bleeding disorders throughout their lives, emphasizing the importance of gathering data to improve future management.
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Affiliation(s)
- Cedric Hermans
- Division of Hematology, Hemostasis and Thrombosis Unit, Saint-Luc University Hospital, Université catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Jill M Johnsen
- Department of Medicine, University of Washington, Seattle, Washington, USA
- Institute for Stem Cell & Regenerative Medicine, University of Washington, Seattle, Washington, USA
- Center for Cardiovascular Biology, University of Washington, Seattle, Washington, USA
| | - Nicola Curry
- Radcliffe Department of Medicine, Oxford University Hospitals NHS Foundation Trust, Nuffield Orthopedic Centre, Oxford University, Oxford, UK
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Baker RI, Choi P, Curry N, Gebhart J, Gomez K, Henskens Y, Heubel-Moenen F, James P, Kadir RA, Kouides P, Lavin M, Lordkipanidze M, Lowe G, Mumford A, Mutch N, Nagler M, Othman M, Pabinger I, Sidonio R, Thomas W, O'Donnell JS. Standardization of definition and management for bleeding disorder of unknown cause: communication from the SSC of the ISTH. J Thromb Haemost 2024:S1538-7836(24)00163-6. [PMID: 38518896 DOI: 10.1016/j.jtha.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 02/08/2024] [Accepted: 03/08/2024] [Indexed: 03/24/2024]
Abstract
In many patients referred with significant bleeding phenotype, laboratory testing fails to define any hemostatic abnormalities. Clinical practice with respect to diagnosis and management of this patient cohort poses significant clinical challenges. We recommend that bleeding history in these patients should be objectively assessed using the International Society on Thrombosis and Haemostasis (ISTH) bleeding assessment tool. Patients with increased bleeding assessment tool scores should progress to hemostasis laboratory testing. To diagnose bleeding disorder of unknown cause (BDUC), normal complete blood count, prothrombin time, activated partial thromboplastin time, thrombin time, von Willebrand factor antigen, von Willebrand factor function, coagulation factors VIII, IX, and XI, and platelet light transmission aggregometry should be the minimum laboratory assessment. In some laboratories, additional specialized hemostasis testing may be performed to identify other rare causes of bleeding. We recommend that patients with a significant bleeding phenotype but normal laboratory investigations should be registered with a diagnosis of BDUC in preference to other terminology. Global hemostatic tests and markers of fibrinolysis demonstrate variable abnormalities, and their clinical significance remains uncertain. Targeted genomic sequencing examining candidate hemostatic genes has a low diagnostic yield. Underlying BDUC should be considered in patients with heavy menstrual bleeding since delays in diagnosis often extend to many years and negatively impact quality of life. Treatment options for BDUC patients include tranexamic acid, desmopressin, and platelet transfusions.
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Affiliation(s)
- Ross I Baker
- Western Australia Centre for Thrombosis and Haemostasis, Murdoch University, Perth, Australia; Perth Blood Institute, Clinical Research Unit, Perth, Australia; Hollywood Hospital Haemophilia Centre, Haematology Academic Unit, Perth, Australia; Irish-Australian Blood Collaborative Network, Royal College of Surgeons in Ireland, Ireland; Perth Blood Institute, Perth, Australia.
| | - Philip Choi
- Haematology Department, The Canberra Hospital, Canberra, Australia; Division of Genome Sciences and Cancer, John Curtin School of Medical Research, Australian National University, Canberra, Australia
| | - Nicola Curry
- Department of Clinical Haematology, Haemophilia & Thrombosis Centre, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom; Radcliffe Department of Medicine, Oxford University, Oxford, United Kingdom
| | - Johanna Gebhart
- Department of Medicine, Division of Hematology and Hemostaseology, Medical University Vienna, Vienna, Austria
| | - Keith Gomez
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit, Royal Free London National Health Service Foundation Trust, London, United Kingdom
| | - Yvonne Henskens
- Central Diagnostic Laboratory, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Biochemistry, Institute for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Floor Heubel-Moenen
- Department of Hematology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Paula James
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Rezan Abdul Kadir
- Department of Obstetrics and Gynaecology, Katharine Dormandy Haemophilia and Thrombosis Centre, The Royal Free National Health Service Hospital, London, United Kingdom; Institute for Women's Health, University College, London, United Kingdom
| | - Peter Kouides
- Mary M. Gooley Hemophilia Center, Rochester, New York, USA
| | - Michelle Lavin
- Irish-Australian Blood Collaborative Network, Royal College of Surgeons in Ireland, Ireland; Perth Blood Institute, Perth, Australia; National Coagulation Centre, St. James's Hospital, Dublin, Ireland; Irish Centre for Vascular Biology, School of Pharmacy & Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Marie Lordkipanidze
- Research Center, Montreal Heart Institute, Montreal, Quebec, Canada; Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada
| | - Gillian Lowe
- West Midlands Adult Comprehensive Care Haemophilia Centre, University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, United Kingdom
| | - Andrew Mumford
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, United Kingdom
| | - Nicola Mutch
- Aberdeen Cardiovascular and Diabetes Centre, Institute of Medical Sciences, School of Medicine, United Kingdom; Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
| | - Michael Nagler
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, Bern, Switzerland; Department of Clinical Chemistry, Inselspital University Hospital Bern, Bern, Switzerland
| | - Maha Othman
- Department of Biomedical and Molecular Sciences, School of Medicine, Queen's University, Kingston, Ontario, Canada; School of Baccalaureate Nursing, St Lawrence College, Kingston, Ontario, Canada; Clinical Pathology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Ingrid Pabinger
- Department of Medicine, Division of Hematology and Hemostaseology, Medical University Vienna, Vienna, Austria
| | - Robert Sidonio
- Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Will Thomas
- Department of Haematology, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
| | - James S O'Donnell
- Irish-Australian Blood Collaborative Network, Royal College of Surgeons in Ireland, Ireland; Perth Blood Institute, Perth, Australia; National Coagulation Centre, St. James's Hospital, Dublin, Ireland; Irish Centre for Vascular Biology, School of Pharmacy & Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
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VanderMeulen H, Tang GH, Sholzberg M. Tranexamic acid for management of heavy vaginal bleeding: barriers to access and myths surrounding its use. Res Pract Thromb Haemost 2024; 8:102389. [PMID: 38623473 PMCID: PMC11017359 DOI: 10.1016/j.rpth.2024.102389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 03/09/2024] [Accepted: 03/11/2024] [Indexed: 04/17/2024] Open
Abstract
Tranexamic acid is safe and effective for the treatment of heavy vaginal bleeding during menstruation and childbirth. It improves the quality of life, facilitates participation in school and work, and reduces the risk of death from postpartum hemorrhage. Despite its well-established benefits, individual- and structural-level barriers preclude its widespread utilization, hindering effective patient care and perpetuating health inequities in women's health. We first describe the evidence for the use of tranexamic acid in treating heavy menstrual bleeding and postpartum hemorrhage. Barriers to tranexamic acid use, including structural sexism, period poverty, misinformation in product monograph labeling, stigmatization of vaginal blood loss, and drug access, are then discussed. Finally, we summarize relevant data presented during the 2023 International Society on Thrombosis and Haemostasis Congress.
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Affiliation(s)
- Heather VanderMeulen
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Grace H. Tang
- Department of Hematology, Hematology-Oncology Clinical Research Group, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Michelle Sholzberg
- Department of Medicine and Laboratory Medicine & Pathobiology, St. Michael’s Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
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Sharma R, Johnson V, Pan A, Sellers A, Betensky M, Goldenberg N, Flood VH. Assessment of rare bleeding disorders in adolescents with heavy menstrual bleeding. Haemophilia 2024; 30:490-496. [PMID: 38385952 DOI: 10.1111/hae.14961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/04/2024] [Accepted: 01/11/2024] [Indexed: 02/23/2024]
Abstract
INTRODUCTION There are a significant number of patients with mucocutaneous bleeding, specifically heavy menstrual bleeding (HMB), who do not have a diagnosed bleeding disorder. These patients receive nontargeted interventions and may have suboptimal treatments. Functional assays, particularly for fibrinolytic and rare platelet function defects, are not robust and not readily available. AIM We aimed to prospectively evaluate the prevalence of genetic defects associated with rare bleeding disorders and describe alterations of coagulation and fibrinolysis in a cohort of adolescents with HMB. METHODS We performed a prospective observational cohort study of patients with HMB and unexplained bleeding. The study utilized a next generation sequencing panel and investigational global assays of coagulation and fibrinolysis. Additionally, specific functional assays were performed to help characterize novel variants that were identified. RESULTS In 10 of the 17 patients (∼59%), genetic variants were identified on molecular testing. Thrombin generation by calibrated thromboelastography was not significantly altered in this patient population. The clot formation and lysis assay showed a trend towards increased fibrinolysis with rapid phase of decline in 23% of the patients. Further corresponding functional assays and study population are described. CONCLUSION Our study describes a unique correlative model in a homogenous cohort of patients with HMB and unexplained bleeding which may inform future diagnostic algorithms, genotype-phenotype correlations as well as aid in specific targeted treatment approaches. Larger future studies may inform risk stratification of patients and improve health related outcomes in patients with HMB.
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Affiliation(s)
- Ruchika Sharma
- Division of Hematology/Oncology/BMT, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Victoria Johnson
- Center for Comprehensive Bleeding Disorders, Versiti Blood Center of Wisconsin, Milwaukee, Wisconsin, USA
| | - Amy Pan
- Division of Pediatric Hematology/Oncology/BMT, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Austin Sellers
- Institute for Clinical and Translational Research, John Hopkins All Childrens Hospital, St. Petersburg, Florida, USA
| | - Marisol Betensky
- Institute for Clinical and Translational Research, John Hopkins All Childrens Hospital, St. Petersburg, Florida, USA
| | - Neil Goldenberg
- Institute for Clinical and Translational Research, John Hopkins All Childrens Hospital, St. Petersburg, Florida, USA
| | - Veronica H Flood
- Center for Comprehensive Bleeding Disorders, Versiti Blood Center of Wisconsin, Milwaukee, Wisconsin, USA
- Division of Pediatric Hematology/Oncology/BMT, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Mao C, Liu X, Guo SW. Meclizine improves endometrial repair and reduces simulated menstrual bleeding in mice with induced adenomyosis. Am J Obstet Gynecol 2024:S0002-9378(24)00088-7. [PMID: 38367751 DOI: 10.1016/j.ajog.2024.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/31/2024] [Accepted: 02/11/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND Adenomyosis is one of the structural causes of abnormal uterine bleeding, which often presents as heavy menstrual bleeding. Mostly because of the poor understanding of its pathophysiology, medical management of adenomyosis-induced heavy menstrual bleeding is still a challenge. We have previously reported that glycolysis is crucial to endometrial repair following menstruation and that suppressed glycolysis can cause heavy menstrual bleeding. OBJECTIVE This study aimed to test the hypothesis that meclizine, a drug with an excellent safety profile, alleviates heavy menstrual bleeding in mice with induced adenomyosis using a simulated menstruation model. STUDY DESIGN Adenomyosis was induced in 36 female C57BL/6 mice using endometrial-myometrial interface disruption. Three months after induction, the mice were randomly divided into the following 3 groups: low-dose meclizine, high-dose meclizine, and controls. Treatment with meclizine or vehicle started shortly before the simulated menstruation procedure and ended before progesterone withdrawal. The amount of blood loss was quantified and uterine tissue was harvested for histologic evaluation of the grade of endometrial repair. We performed immunohistochemistry analysis of 4 proteins critically involved in glycolysis: Glut1 (glucose transporter 1), Hk2 (hexokinase 2), Pfkfb3 (6-phosphofructo-2-kinase/fructose-2,6-biphosphatase 3), and Pkm2 (pyruvate kinase M2). The extent of tissue fibrosis in both ectopic and eutopic endometria was evaluated using Masson trichrome staining. RESULTS In mice with induced adenomyosis, meclizine accelerated endometrial repair in a dose-dependent manner and reduced the amount of menstrual bleeding. Meclizine administration raised endometrial immunoexpression of Hk2 and Pfkfb3 but not of Glut1 or Pkm2. The extent of endometrial fibrosis was reduced following the meclizine administration. Remarkably, these favorable changes were accompanied by the suppression of lesional progression, as evidenced by the dose-dependent reduction in the extent of fibrosis (a surrogate for lesional progression). CONCLUSION These encouraging results, taken together, suggest that glycolysis may be a promising therapeutic target and that meclizine may hold therapeutic potential as a nonhormonal treatment for adenomyosis-induced heavy menstrual bleeding without exacerbating the disease.
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Affiliation(s)
- Chenyu Mao
- Department of General Gynecology, Obstetrics & Gynecology Hospital, Fudan University, Shanghai, China
| | - Xishi Liu
- Department of General Gynecology, Obstetrics & Gynecology Hospital, Fudan University, Shanghai, China
| | - Sun-Wei Guo
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Fudan University, Shanghai, China; Research Institute, Obstetrics & Gynecology Hospital, Fudan University, Shanghai, China.
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Fazmiya MJA, Sultana A, Heyat MBB, Parveen S, Rahman K, Akhtar F, Khan AA, Alanazi AM, Ahmed Z, Díez IDLT, Ballester JB, Saripalli TSK. Efficacy of a vaginal suppository formulation prepared with Acacia arabica (Lam.) Willd. gum and Cinnamomum camphora (L.) J. Presl. in heavy menstrual bleeding analyzed using a machine learning technique. Front Pharmacol 2024; 15:1331622. [PMID: 38410133 PMCID: PMC10894987 DOI: 10.3389/fphar.2024.1331622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 01/16/2024] [Indexed: 02/28/2024] Open
Abstract
Objective: This study aims to determine the efficacy of the Acacia arabica (Lam.) Willd. and Cinnamomum camphora (L.) J. Presl. vaginal suppository in addressing heavy menstrual bleeding (HMB) and their impact on participants' health-related quality of life (HRQoL) analyzed using machine learning algorithms. Method: A total of 62 participants were enrolled in a double-dummy, single-center study. They were randomly assigned to either the suppository group (SG), receiving a formulation prepared with Acacia arabica gum (Gond Babul) and camphor from Cinnamomum camphora (Kafoor) through two vaginal suppositories (each weighing 3,500 mg) for 7 days at bedtime along with oral placebo capsules, or the tranexamic group (TG), receiving oral tranexamic acid (500 mg) twice a day for 5 days and two placebo vaginal suppositories during menstruation at bedtime for three consecutive menstrual cycles. The primary outcome was the pictorial blood loss assessment chart (PBLAC) for HMB, and secondary outcomes included hemoglobin level and SF-36 HRQoL questionnaire scores. Additionally, machine learning algorithms such as k-nearest neighbor (KNN), AdaBoost (AB), naive Bayes (NB), and random forest (RF) classifiers were employed for analysis. Results: In the SG and TG, the mean PBLAC score decreased from 635.322 ± 504.23 to 67.70 ± 22.37 and 512.93 ± 283.57 to 97.96 ± 39.25, respectively, at post-intervention (TF3), demonstrating a statistically significant difference (p < 0.001). A higher percentage of participants in the SG achieved normal menstrual blood loss compared to the TG (93.5% vs 74.2%). The SG showed a considerable improvement in total SF-36 scores (73.56%) compared to the TG (65.65%), with a statistically significant difference (p < 0.001). Additionally, no serious adverse events were reported in either group. Notably, machine learning algorithms, particularly AB and KNN, demonstrated the highest accuracy within cross-validation models for both primary and secondary outcomes. Conclusion: The A. arabica and C. camphora vaginal suppository is effective, cost-effective, and safe in controlling HMB. This botanical vaginal suppository provides a novel and innovative alternative to traditional interventions, demonstrating promise as an effective management approach for HMB.
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Affiliation(s)
- Mohamed Joonus Aynul Fazmiya
- Department of Ilmul Qabalat wa Amraze Niswan, National Institute of Unani Medicine, Ministry of AYUSH, Bengaluru, India
| | - Arshiya Sultana
- Department of Ilmul Qabalat wa Amraze Niswan, National Institute of Unani Medicine, Ministry of AYUSH, Bengaluru, India
| | - Md Belal Bin Heyat
- CenBRAIN Neurotech Center of Excellence, School of Engineering, Westlake University, Hangzhou, China
| | - Saba Parveen
- College of Electronics and Information Engineering, Shenzhen University, Shenzhen, China
| | - Khaleequr Rahman
- Department of Ilmul Saidla, National Institute of Unani Medicine, Ministry of AYUSH, Bengaluru, India
| | - Faijan Akhtar
- School of Computer Science and Engineering, University of Electronic Science and Technology of China, Chengdu, China
| | - Azmat Ali Khan
- Pharmaceutical Biotechnology Laboratory, Department of Pharmaceutical Chemistry, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Amer M. Alanazi
- Pharmaceutical Biotechnology Laboratory, Department of Pharmaceutical Chemistry, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Zaheer Ahmed
- Central Council for Research in Unani Medicine, New Delhi, India
| | | | - Julién Brito Ballester
- Research Group on Foods, Nutritional Biochemistry and Health, Universidad Europea del Atlántico, Santander, Spain
- Research Group on Foods, Nutritional Biochemistry and Health, Universidad Internacional Iberoamericana, Arecibo, PR, United States
- Research Group on Foods, Nutritional Biochemistry and Health, Universidad de La Romana, La Romana, Dominican Republic
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Stewart EA, Al-Hendy A, Lukes AS, Madueke-Laveaux OS, Zhu E, Proehl S, Schulmann T, Marsh EE. Relugolix combination therapy in Black/African American women with symptomatic uterine fibroids: LIBERTY Long-Term Extension study. Am J Obstet Gynecol 2024; 230:237.e1-237.e11. [PMID: 37863160 DOI: 10.1016/j.ajog.2023.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 10/05/2023] [Accepted: 10/16/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND In the LIBERTY Long-Term Extension study, once-daily relugolix combination therapy (40 mg relugolix, estradiol 1 mg, norethindrone acetate 0.5 mg) substantially improved uterine fibroid-associated heavy menstrual bleeding throughout the 52-week treatment period in the overall study population. OBJECTIVE Black or African American women typically experience a greater extent of disease and symptom burden of uterine fibroids vs other racial groups and have traditionally been underrepresented in clinical trials. This secondary analysis aimed to assess the efficacy and safety of relugolix combination therapy in the subgroup population of Black or African American women with uterine fibroids in the LIBERTY Long-Term Extension study. STUDY DESIGN Black or African American premenopausal women (aged 18-50 years) with uterine fibroids and heavy menstrual bleeding who completed the 24-week randomized, placebo-controlled, double-blind LIBERTY 1 (identifier: NCT03049735) or LIBERTY 2 (identifier: NCT03103087) trials were eligible to enroll in the 28-week LIBERTY Long-Term Extension study (identifier: NCT03412890), in which all women received once-daily, open-label relugolix combination therapy. The primary endpoint of this subanalysis was the proportion of Black or African American treatment responders: women who achieved a menstrual blood loss volume of <80 mL and at least a 50% reduction in menstrual blood loss volume from the pivotal study baseline to the last 35 days of treatment by pivotal study randomized treatment group. The secondary outcomes included rates of amenorrhea and changes in symptom burden and quality of life. RESULTS Overall, 241 of 477 women (50.5%) enrolled in the LIBERTY Long-Term Extension study self-identified as Black or African American. In Black or African American women receiving continuous relugolix combination therapy for up to 52 weeks, 58 of 70 women (82.9%; 95% confidence interval, 72.0%-90.8%) met the treatment responder criteria for reduction in heavy menstrual bleeding (primary endpoint). A substantial reduction in menstrual blood loss volume from the pivotal study baseline to week 52 was demonstrated (least squares mean percentage change: 85.0%); 64.3% of women achieved amenorrhea; 59.1% of women with anemia at the pivotal study baseline achieved a substantial improvement (>2 g/dL) in hemoglobin levels; and decreased symptom severity and distress because of uterine fibroid-associated symptoms and improvements in health-related quality of life through 52 weeks were demonstrated. The most frequently reported adverse events during the cumulative 52-week treatment period were hot flush (12.9%), headache (5.7%), and hypertension (5.7%). Bone mineral density was preserved through 52 weeks. CONCLUSION Once-daily relugolix combination therapy improved uterine fibroid-associated heavy menstrual bleeding in most Black or African American women who participated in the LIBERTY Long-Term Extension study. The safety and efficacy profile of relugolix combination therapy in Black or African American women was consistent with previously published results from the overall study population through 52 weeks. Findings from this subanalysis will assist shared decision-making by helping providers and Black or African American women understand the efficacy and safety of relugolix combination therapy as a pharmacologic option for the management of uterine fibroid-associated symptoms.
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Affiliation(s)
- Elizabeth A Stewart
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN.
| | - Ayman Al-Hendy
- Department of Obstetrics and Gynecology, University of Illinois at Chicago, Chicago, IL
| | - Andrea S Lukes
- Carolina Women's Research and Wellness Center, Durham, NC
| | | | | | | | | | - Erica E Marsh
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI
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James AH, James PD. What do we know about why women bleed and what do we not know? J Thromb Haemost 2024; 22:315-322. [PMID: 37709147 DOI: 10.1016/j.jtha.2023.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 08/07/2023] [Accepted: 08/31/2023] [Indexed: 09/16/2023]
Abstract
Women or people with a uterus are vulnerable to both normal and abnormal bleeding. During the reproductive years, the uterus is prepared physiologically to accept an embryo and support its growth and development during pregnancy, or in the absence of implantation of an embryo, recycle through the process of menstruation and accept an embryo a month or so later. If fertilization takes place and an embryo or embryos implant in the uterus, the fetal trophoblast, or outer cell layer of the embryo, invades and dilates the maternal spiral arteries and forms the placenta. No matter when in gestation a pregnancy ends, at the conclusion of pregnancy, the placenta should separate from the wall of the uterus and be expelled. Abnormal bleeding occurs during pregnancy or after delivery when the normal uteroplacental interface has not been established or is interrupted; during miscarriage; during ectopic pregnancy; during premature separation of the placenta; or during postpartum hemorrhage. Heavy menstrual bleeding, a subset of abnormal menstrual bleeding, can be quantitatively defined as >80 mL of blood loss per cycle. Unlike postpartum hemorrhage, heavy menstrual bleeding is significantly associated with an underlying bleeding disorder. While there is other reproductive tract bleeding in women, notably bleeding at the time of ovulation or with a life-threatening ruptured ectopic pregnancy, the unique bleeding that women experience is predominantly uterine in origin. Many of the unique aspects of uterine hemostasis, however, remain unknown.
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Affiliation(s)
- Andra H James
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, Durham, USA; Division of Hematology, Department of Medicine, Duke University Medical Center, Durham, Durham, USA.
| | - Paula D James
- Departments of Medicine and Pathology & Molecular Medicine, Queen's University, Kingston, Ontario, Canada
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Alhammadi MH, Alsaif AA, AlGhamdi DA, Albasri S. Distribution of ABO and Rh Blood Groups in Patients With Endometriosis at King Abdulaziz University Hospital: A Case-Control Study. Cureus 2023; 15:e51268. [PMID: 38283422 PMCID: PMC10822122 DOI: 10.7759/cureus.51268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/26/2023] [Indexed: 01/30/2024] Open
Abstract
Background There is no sound evidence for the association of blood groups with the risk of endometriosis, and no studies from Saudi Arabia have examined this association. Therefore, the primary aim was to determine whether there is an association between the distribution of ABO and Rh blood groups and the incidence of endometriosis in a cohort from Saudi Arabia and also to evaluate the potential risk factors related to endometriosis among the population. Methods This case-control study included women diagnosed with endometriosis (n = 44) who presented to King Abdulaziz University Hospital Obstetrics and Gynecology Clinic, Jeddah, Saudi Arabia, between 2010 and 2021. Women from the blood donors database of King Abdulaziz University Hospital were included as a control group (n = 184). The total sample size was 228. Demographic data, diagnosis method, ABO blood type, and Rh blood type were obtained from hospital records. In addition, data were collected from self-reported questionnaires, which included family history, dysmenorrhea, age of menarche, age of childbearing, number of children, history of abortion, parity, number of children, use of oral contraceptives for alleviating dysmenorrhea, iron deficiency, duration of menstrual flow, and volume of bleeding during menses. Odds ratio, Pearson chi-squared test (χ2), and independent t-test were used to analyze the associations between variables. Results Most of the participants had blood type O (n = 117, 51.3%), which was followed by blood type A (n = 59, 26.0%), and the majority were Rh+ (n = 215, 94.3%). There was no significant difference in the risk of endometriosis according to ABO (P = 0.237) and Rh (P = 0.283) blood types. However, endometriosis was found to have a significant relationship with dysmenorrhea, heavy bleeding during menses, history of abortion, long duration of menstrual flow, lower number of children, late pregnancy, and use of oral contraceptive pills to relieve dysmenorrhea (p ≤ 0.05). Conclusions The present results indicate that ABO and Rh blood types are not associated with the risk of endometriosis. However, there was a strong, significant association between endometriosis and other factors.
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Affiliation(s)
| | - Afnan A Alsaif
- Faculty of Medicine, King Abdulaziz University, Jeddah, SAU
| | | | - Samera Albasri
- Obstetrics and Gynecology, King Abdulaziz University Hospital, Jeddah, SAU
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Matteson KA, Valcin J, Raker CA, Clark MA. A randomized trial comparing the 52-mg levonorgestrel system with combination oral contraceptives for treatment of heavy menstrual bleeding. Am J Obstet Gynecol 2023; 229:532.e1-532.e13. [PMID: 37536486 DOI: 10.1016/j.ajog.2023.07.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 07/24/2023] [Accepted: 07/26/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND The levonorgestrel intrauterine system and combined oral contraceptives are the 2 most commonly used nonsurgical treatments for heavy menstrual bleeding in the United States. However, there are limited data on their relative effectiveness and on their impact on bleeding-specific quality of life. OBJECTIVE This study aimed to compare the effectiveness of the 52-mg levonorgestrel intrauterine system with that of combined oral contraceptives for improving quality of life among individuals who self-report heavy menstrual bleeding. We hypothesized that the levonorgestrel intrauterine system would be more effective than combined oral contraceptives at 6 and 12 months after treatment. STUDY DESIGN We conducted a pragmatic randomized trial of individuals who self-reported heavy menstrual bleeding. Individuals were eligible if they did not have contraindications to either the levonorgestrel intrauterine system or combined oral contraceptives and were determined to have a nonstructural cause of heavy menstrual bleeding. Eligible and consenting participants were randomly assigned in a 1:1 ratio to receive a 52-mg levonorgestrel intrauterine system or a monophasic 30- or 35-μg ethinyl estradiol-containing combined oral contraceptive. The main outcome was mean change in bleeding-related quality of life, measured by the 20-question Menstrual Bleeding Questionnaire (score range, 0-75) at 6 and 12 months. Differences in group means and confidence intervals for the Menstrual Bleeding Questionnaire score were computed by multivariable linear mixed-effects regression; 24 participants per group were needed to detect a 10-point difference in change in mean Menstrual Bleeding Questionnaire score between individuals treated with the levonorgestrel intrauterine system and those treated with combined oral contraceptives at each follow-up time point. RESULTS A total of 62 individuals were randomly assigned to treatment (n=29 allocated to levonorgestrel intrauterine system and n=33 allocated to combined oral contraceptives) and included in the intention-to-treat analyses; 19 of 29 received the levonorgestrel intrauterine system and 31 of 33 received combined oral contraceptives. Eleven percent identified as Black or African American and 44% identified as Hispanic or Latina. Participant characteristics were similar among study groups. Bleeding-related quality of life increased in both study arms, as reflected by a significant decrease in Menstrual Bleeding Questionnaire scores beginning at 6-week follow-up. In the main intention-to-treat analyses (n=62), there were no differences in mean change in Menstrual Bleeding Questionnaire scores at 6 months (difference=-2.5; 95% confidence interval, -10.0 to +5.0) or 12 months (difference=-1.1; 95% confidence interval, -8.7 to +6.5). Findings were similar in the subsets of participants with any follow-up visits (n=52) and who completed all follow-up visits (n=42). In the per-protocol analyses (n=47), a significantly greater decrease in Menstrual Bleeding Questionnaire score was observed in the levonorgestrel intrauterine system arm at 6 months after treatment (difference=-7.0; 95% confidence interval, -13.8 to -0.2) but not at 12 months (difference=-4.8; 95% confidence interval, -11.8 to 2.3) compared with the combined oral contraceptive arm. CONCLUSION No differences in change of bleeding-related quality of life were observed between the levonorgestrel intrauterine system and combined oral contraceptives at 6 or 12 months. Patients should be counseled that the levonorgestrel intrauterine system and combined oral contraceptives are both effective options for improving bleeding-related quality of life.
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Affiliation(s)
- Kristen A Matteson
- Department of Obstetrics and Gynecology, Women & Infants Hospital of Rhode Island, Warren Alpert Medical School of Brown University, Providence, RI.
| | - Josie Valcin
- Warren Alpert Medical School of Brown University, Providence, RI
| | - Christina A Raker
- Department of Obstetrics and Gynecology, Women & Infants Hospital of Rhode Island, Warren Alpert Medical School of Brown University, Providence, RI
| | - Melissa A Clark
- Department of Obstetrics and Gynecology, Women & Infants Hospital of Rhode Island, Warren Alpert Medical School of Brown University, Providence, RI; Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI
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Cohen CT, Zobeck M, Powers JM. Initial von Willebrand factor antigen values in adolescent females predict future values. Haemophilia 2023; 29:1547-1555. [PMID: 37718627 PMCID: PMC10693906 DOI: 10.1111/hae.14865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 08/28/2023] [Accepted: 09/07/2023] [Indexed: 09/19/2023]
Abstract
INTRODUCTION Diagnosing von Willebrand Disease (VWD) in adolescent females is challenging as menstruation and physiologic stress elevate von Willebrand factor (VWF) laboratory values. AIM To develop a VWF prediction model for adolescent females based on initial VWF results. METHODS We identified female patients aged 9 to 21 years with any VWF laboratory test over a 5-year period (2017-2021) at any Texas Children's Hospital facility. Patient demographics, VWF testing, haemoglobin concentration, serum ferritin and site of clinical testing were collected (initial and subsequent laboratory evaluations). A Bayesian linear regression model was developed. Prediction intervals were analysed to identify thresholds for patients in whom repeat testing was unlikely to identify low VWF levels (< 50%), consistent with VWD. RESULTS A total of 6125 adolescent females underwent VWF testing; 1204 (19.7%) had repeat testing. Based on the prediction model, initial VWF antigen values of 80%, 90% and ≥100% carried a 92.6%, 96.6% and ≥98.0% probability of having repeat normal repeat VWF values, respectively. Subjects assessed in outpatient adolescent medicine or gynaecology clinics were more likely to have low VWF values compared to those assessed in the acute care setting (p < .001). Median presenting haemoglobin and serum ferritin were 12.4 g/dL and 13 ng/mL, respectively and were similar in those with normal versus low VWF antigen values. CONCLUSION Repeat testing in adolescent females whose initial VWF antigen values are ≥90% is unlikely to identify additional patients with VWD. Iron deficiency screening should be performed in all adolescent females.
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Affiliation(s)
- Clay T. Cohen
- Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine and Texas Children’s Cancer and Hematology Center, Houston, Texas, USA
| | - Mark Zobeck
- Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine and Texas Children’s Cancer and Hematology Center, Houston, Texas, USA
| | - Jacquelyn M. Powers
- Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine and Texas Children’s Cancer and Hematology Center, Houston, Texas, USA
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Al-Hendy A, Zhou YF, Faustmann T, Groettrup-Wolfers E, Laapas K, Parke S, Seitz C. Efficacy and safety of vilaprisan in women with uterine fibroids: data from the ASTEROID 3 randomized controlled trial. F S Sci 2023; 4:317-326. [PMID: 37437885 DOI: 10.1016/j.xfss.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/15/2023] [Accepted: 06/30/2023] [Indexed: 07/14/2023]
Abstract
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).
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Affiliation(s)
- Ayman Al-Hendy
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, Illinois
| | - Ying F Zhou
- Department of Obstetrics and Gynecology, Peking University First Hospital, Xicheng District, Beijing, People's Republic of China
| | | | | | | | | | - Christian Seitz
- Bayer AG, Berlin, Germany; Institute of Clinical Pharmacology and Toxicology, Universitätsmedizin Berlin, Berlin, Germany.
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Litherland NC, Phillips R. Should outpatient hysteroscopy be used in preference to transvaginal ultrasound to identify endometrial pathology in premenopausal women with heavy menstrual bleeding? Revisiting NICE Guideline 88. Ultrasound 2023; 31:284-291. [PMID: 37929243 PMCID: PMC10621496 DOI: 10.1177/1742271x221147731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 11/02/2022] [Indexed: 11/07/2023]
Abstract
Introduction National Institute for Health and Care Excellence Guideline 88 advocates outpatient hysteroscopy in preference to transvaginal ultrasound for premenopausal women with heavy menstrual bleeding, who are suspected of having submucosal fibroids, polyps or endometrial pathology. The guideline, however, analysed outdated studies that provided low-quality evidence. This study aimed to assess the diagnostic accuracy of transvaginal ultrasound in detecting endometrial pathology; and to evaluate the cost-effectiveness of outpatient hysteroscopy if it were to be used in preference to transvaginal ultrasound. Methods A health service evaluation was conducted at a district general foundation trust between 1 January 2019 and 31 March 2019 of all premenopausal women with heavy menstrual bleeding. A cost-effectiveness analysis was also performed to evaluate the financial implication of outpatient hysteroscopy being used in preference to transvaginal ultrasound. Results 100 patients were included in the study. For the detection of endometrial pathology, transvaginal ultrasound had a positive predictive value of 65.2%; negative predictive value of 98.5%; sensitivity of 93.75%; specificity of 88.89% and an accuracy of 89.77%. For identifying endometrial polyps, submucosal fibroids and endometrial thickening, transvaginal ultrasound had a positive predictive value of 33.3%, 85.7% and 50%, respectively. It would have cost the Trust 78.7% more if National Institute for Health and Care Excellence's recommendation was carried out, with a 23.4% increase in workload in the hysteroscopy department, and a decrease of 7.8% transvaginal scans performed. Conclusion Outpatient hysteroscopy is costly and would increase the workload burden in the hysteroscopy department. Transvaginal ultrasound has a high sensitivity, specificity and accuracy in detecting endometrial pathology therefore it should remain as the initial diagnostic investigation.
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Eising HP, Punt MC, Schermer T, Leemans JC, Bongers MY. The ISTH-BAT score and outcomes after endometrial ablation in women with heavy menstrual bleeding. Haemophilia 2023; 29:1573-1579. [PMID: 37758646 DOI: 10.1111/hae.14872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 09/11/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND The International Society on Thrombosis and Haemostasis bleeding assessment tool (ISTH-BAT), is used during the diagnostic workup of bleeding disorders. Data on ISTH-BAT scores in women with heavy menstrual bleeding (HMB) undergoing endometrial ablation (EA) could be essential in optimizing HMB counselling. OBJECTIVE To investigate the postsurgical incidence of amenorrhea, dysmenorrhea, quality of life, re-intervention after EA, and ISTH-BAT score. METHODS This study included women who have undergone EA because of HMB. During a follow-up of 2 to 5 years, ISTH-BAT, pictorial blood assessment chart (PBAC), and Short Form-36 survey (SF-36) were administered. At 10 years of follow-up surgical re-interventions were evaluated. RESULTS Seventy-one women were included of whom 77% (n = 55) had an ISTH-BAT score < 6, versus 23% (n = 16) ISTH-BAT score ≥6 (mean age 46.3 versus 42.3, p = 0.004). In the ISTH-BAT ≥6 group versus < 6 group, amenorrhea occurred in 63% (10/16) versus 82% (45/55) (p = 0.111), dysmenorrhea in 38% (6/16) versus 18% (10/55) (p = 0.111), and surgical re-intervention in 19% (3/16) versus 25% (14/55) (p = 0.582). SF-36 item (Bodily) pain was lower in the ISTH-BAT ≥6 group versus < 6 (median score 58.7 vs. 80.0, p = 0.104). CONCLUSIONS An ISTH-BAT score ≥6 may be related to a lower amenorrhea incidence and higher dysmenorrhea rate after EA.
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Affiliation(s)
- Heleen P Eising
- Department of Gynaecology and Obstetrics, Gelre Hospital, Apeldoorn, The Netherlands
- Grow Research School Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | - Marieke C Punt
- Department of Gynaecology and Obstetrics, Gelre Hospital, Apeldoorn, The Netherlands
| | - Tjard Schermer
- Gelre Leerhuis, Department of Epidemiology, Gelre Hospitals, Apeldoorn, The Netherlands
| | - Jaklien C Leemans
- Department of Gynaecology and Obstetrics, Máxima Medical Center, Veldhoven, The Netherlands
| | - Marlies Y Bongers
- Grow Research School Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
- Department of Gynaecology and Obstetrics, Máxima Medical Center, Veldhoven, The Netherlands
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Agarwal SK, Stokes M, Kung T, Tilney R, Lickert C. Describing the Patient Journey of Women with Claims for Uterine Fibroids and Heavy Menstrual Bleeding Using a Commercial Database (2011-2020). Int J Womens Health 2023; 15:1561-1575. [PMID: 37867928 PMCID: PMC10588720 DOI: 10.2147/ijwh.s420612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 09/26/2023] [Indexed: 10/24/2023] Open
Abstract
Introduction This retrospective database claims analysis describes the clinical characteristics and treatment patterns of commercially insured United States women with uterine fibroids (UF) and heavy menstrual bleeding (HMB). Methods Women age 18-55 years with an incident UF diagnosis (index date) between 1/1/2012 and 12/31/2019 and ≥1 claim for HMB (UF-HMB), were identified from the Optum® Clinformatics® database. Outcomes included clinical characteristics, pharmacologic therapy use, and surgeries/procedures. Regression models were used to identify factors associated with time to post-diagnosis hormonal therapy and hysterectomy. Results A total of 85,428 women had UF-HMB (mean [SD] age, 43.7 [6.4] years). The median follow-up was 3.2 years. After HMB, the most common symptoms were pelvic pressure/pain (27.6%) and backache (17.5%). Within 6 months of UF diagnosis, 40.2% of patients had received only pharmacologic therapy; 25.5% had received no treatment; 24.3% had a hysterectomy, and 10.0% had other procedures. By the end of follow-up, 50.0% had received a hysterectomy. Multiple factors were predictive of a higher likelihood of receiving hormonal therapy (geographic region, infertility, pre-index pregnancy) or hysterectomy (older age, prior hormonal treatment, specific bulk symptoms, White race). Conclusion Within 6 months of UF diagnosis, fewer than one-half of women with UF-HMB had received hormonal therapy, one-quarter received no treatment, and one-quarter had received a hysterectomy or another gynecologic procedure. Patients who received a hysterectomy were more likely to be older, White, and to have bulk symptoms.
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Affiliation(s)
| | | | - Tiffany Kung
- Myovant Sciences, Inc (now known as Sumitomo Pharma America, Inc), Marlborough, MA, USA
| | | | - Cassandra Lickert
- Myovant Sciences, Inc (now known as Sumitomo Pharma America, Inc), Marlborough, MA, USA
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Koga K, Fukui M, Fujisawa M, Suzukamo Y. Impact of diagnosis and treatment of uterine fibroids on quality of life and labor productivity: The Japanese online survey for uterine fibroids and quality of life (JOYFUL survey). J Obstet Gynaecol Res 2023; 49:2528-2537. [PMID: 37524334 DOI: 10.1111/jog.15758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 07/22/2023] [Indexed: 08/02/2023]
Abstract
AIM To investigate the impact of uterine fibroid diagnosis/treatment status on quality of life (QOL) and work productivity in women living in Japan. METHODS Women aged 20-49 years who registered on Macromill were recruited via the opt-in method. They completed an online survey on demographic and uterine fibroid diagnosis/treatment status, 36-Item Short-Form Health Survey, Uterine Fibroid Symptom and Health-Related Quality of Life questionnaire (UFS-QOL), and World Health Organization Health and Work Performance Questionnaire. RESULTS There were 4120 respondents: 1362 untreated, 249 with ongoing treatment, 449 with past treatment, 1030 with no uterine fibroids, and 1030 with unknown uterine fibroid status. A high proportion of women with ongoing treatment had moderate to severe uterine fibroid-like symptoms (symptom severity score of UFS-QOL ≥40 points), accompanied by reduced QOL. QOL was improved in women with past treatment. Uterine fibroids had a significant impact on physical and psychosocial aspects in the ongoing treatment group versus other groups. Using classification and regression tree analysis, anemia was identified as a plausible predictor of reduced QOL in the ongoing treatment group. Approximately 20% of women-even in groups other than the ongoing treatment group-experienced moderate to severe uterine fibroid-like symptoms. However, the diagnosis and treatment status of uterine fibroids had no clear impact on work productivity. CONCLUSIONS Uterine fibroids, especially in association with anemia, were related to reduced QOL. Given that uterine fibroid-related reduced QOL is likely improved by appropriate treatment, women with uterine fibroid-like symptoms, such as menorrhagia, should be examined and treated.
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Affiliation(s)
- Kaori Koga
- Department of Gynecologic Surgery, The University of Tokyo Hospital, Tokyo, Japan
- Department of Reproductive Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | | | | | - Yoshimi Suzukamo
- Department of Physical Medicine and Rehabilitation, Tohoku University Graduate School of Medicine, Sendai, Japan
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Cooper NAM, Rivas C, Munro MG, Critchley HOD, Clark TJ, Matteson KA, Papadantonaki R, Yorke S, Tan A, Bofill Rodriguez M, Bongers M, Al-Hendy A, Bahamondes L, Connolly A, Farquhar C, Gray Valbrun T, Hickey M, Taylor HS, Toub D, Vannuccini S, Iliodromiti S, Khan K. Standardising outcome reporting for clinical trials of interventions for heavy menstrual bleeding: Development of a core outcome set. BJOG 2023; 130:1337-1345. [PMID: 37055716 DOI: 10.1111/1471-0528.17473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 02/20/2023] [Accepted: 02/22/2023] [Indexed: 04/15/2023]
Abstract
OBJECTIVE To develop a core outcome set for heavy menstrual bleeding (HMB). DESIGN Core outcome set (COS) development methodology described by the COMET initiative. SETTING University hospital gynaecology department, online international survey and web-based international consensus meetings. POPULATION OR SAMPLE An international collaboration of stakeholders (clinicians, patients, academics, guideline developers) from 20 countries and 6 continents. METHODS Phase 1: Systematic review of previously reported outcomes to identify potential core outcomes. Phase 2: Qualitative studies with patients to identify outcomes most important to them. Phase 3: Online two-round Delphi survey to achieve consensus about which outcomes are most important. Phase 4: A consensus meeting to finalise the COS. MAIN OUTCOME MEASURES Outcome importance was assessed in the Delphi survey on a 9-point scale. RESULTS From the 'long list' of 114, 10 outcomes were included in the final COS: subjective blood loss; flooding; menstrual cycle metrics; severity of dysmenorrhoea; number of days with dysmenorrhoea; quality of life; adverse events; patient satisfaction; number of patients going on to have further treatment for HMB and haemoglobin level. CONCLUSIONS The final COS includes variables that are feasible for use in clinical trials in all resource settings and apply to all known underlying causes of the symptom of HMB. These outcomes should be reported in all future trials of interventions, their systematic reviews, and clinical guidelines to underpin policy.
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Affiliation(s)
- Natalie A M Cooper
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University London, London, UK
| | - Carol Rivas
- Social Research Institute, UCL Institute of Education, London, UK
| | - Malcolm G Munro
- Department of Obstetrics & Gynecology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | | | - T Justin Clark
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Kristen A Matteson
- University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | | | - Sarah Yorke
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University London, London, UK
| | - Alex Tan
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University London, London, UK
| | | | - Marlies Bongers
- Department of Obstetrics and Gynaecology, Grow-School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Ayman Al-Hendy
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, Illinois, USA
| | - Luis Bahamondes
- Department of Obstetrics and Gynaecology, School of Medical Sciences, Universidade Estadual de Campinas, Campinas, Brazil
| | | | - Cindy Farquhar
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | | | - Martha Hickey
- Department of Obstetrics and Gynaecology, University of Melbourne and The Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Hugh S Taylor
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - David Toub
- Medical Affairs, Gynesonics, Redwood City, California, USA
| | - Silvia Vannuccini
- Department of Obstetrics and Gynaecology, Careggi University Hospital, Florence, Italy
| | - Stamatina Iliodromiti
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University London, London, UK
| | - Khalid Khan
- Department of Preventive Medicine and Public Health, University of Granada, Faculty of Medicine, Granada, Spain
- CIBER Epidemiology and Public Health, Madrid, Spain
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Van ‘t Klooster SJ, de Vaan A, van Leeuwen J, Pekel L, van Rijn-van Kortenhof NM, Engelen ET, van Greevenbroek W, Huisman A, Fischer K, Schutgens RE, van Galen KP. Heavy menstrual bleeding in adolescents: incidence, diagnostics, and management practices in primary care. Res Pract Thromb Haemost 2023; 7:102229. [PMID: 38077824 PMCID: PMC10704495 DOI: 10.1016/j.rpth.2023.102229] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 09/21/2023] [Accepted: 09/22/2023] [Indexed: 02/25/2024] Open
Abstract
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.
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Affiliation(s)
- Stella J. Van ‘t Klooster
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Anne de Vaan
- Center for Benign Hematology, Thrombosis and Hemostasis, van Creveldkliniek, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Jeanette van Leeuwen
- Department of Reproductive Medicine & Gynaecology, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Lynnda Pekel
- Netherlands Hemophilia Patients Society, Nijkerk, Gelderland, The Netherlands
| | | | - Eveline T. Engelen
- Dutch Healthcare Network for Women With Bleeding Disorders, UMC Utrecht, Utrecht, the Netherlands
| | - Willie van Greevenbroek
- Center for Benign Hematology, Thrombosis and Hemostasis, van Creveldkliniek, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Albert Huisman
- Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Kathelijn Fischer
- Center for Benign Hematology, Thrombosis and Hemostasis, van Creveldkliniek, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Roger E.G. Schutgens
- Center for Benign Hematology, Thrombosis and Hemostasis, van Creveldkliniek, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Karin P.M. van Galen
- Center for Benign Hematology, Thrombosis and Hemostasis, van Creveldkliniek, University Medical Center, University Utrecht, Utrecht, The Netherlands
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23
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Duijster JW, Schoep ME, Nieboer TE, Jajou R, Kant A, van Hunsel F. Menstrual abnormalities after COVID-19 vaccination in the Netherlands: A description of spontaneous and longitudinal patient-reported data. Br J Clin Pharmacol 2023; 89:3126-3138. [PMID: 37222170 DOI: 10.1111/bcp.15799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/06/2023] [Accepted: 05/16/2023] [Indexed: 05/25/2023] Open
Abstract
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.
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Affiliation(s)
- Janneke W Duijster
- Netherlands Pharmacovigilance Centre Lareb, 's-Hertogenbosch, The Netherlands
| | - Mark E Schoep
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Theodoor E Nieboer
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rana Jajou
- Netherlands Pharmacovigilance Centre Lareb, 's-Hertogenbosch, The Netherlands
| | - Agnes Kant
- Netherlands Pharmacovigilance Centre Lareb, 's-Hertogenbosch, The Netherlands
| | - Florence van Hunsel
- Netherlands Pharmacovigilance Centre Lareb, 's-Hertogenbosch, The Netherlands
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24
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Vitale SG, Moore O, Riemma G, Carugno J, Yarto ML, Haimovich S. Hysteroscopic laser ablation of symptomatic uterine fibroids: insights from a prospective study. Climacteric 2023; 26:497-502. [PMID: 37165870 DOI: 10.1080/13697137.2023.2205581] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/03/2023] [Accepted: 04/14/2023] [Indexed: 05/12/2023]
Abstract
OBJECTIVE This study aimed to evaluate the feasibility and efficacy of in-office hysteroscopic ablation of submucous uterine fibroids using a diode laser. METHOD A pilot study was conducted between January 2018 and January 2019 in a tertiary care university hospital. Patients with at least one symptomatic, class 0-2 FIGO classification, uterine fibroid ≤7 cm in size were eligible for inclusion. Evaluation of the changes in fibroid size and vascularity was performed using three-dimensional Doppler ultrasonography. Vaporization of the fibroid core was conducted using a 980-1470 nm wavelength diode laser inserted through the hysteroscope's working channel. The primary outcome was evaluation of the fibroid volume before and at 2 months after the procedure. RESULTS Twenty women were enrolled in the study. At 2-month follow-up, the volume of the fibroids was significantly reduced (51.6 ± 22.5 vs. 33.4 ± 17.1 mm3; p < 0.001). A major reduction of three-dimensional sonographic color Doppler vascularity (observed by the same operator and confirmed by four blind reviewers) was also achieved in 12/20 patients (60%; p = 0.03) while a reported symptom of heavy menstrual bleeding decreased from 18/20 (90%) to 2/18 (10%; p < 0.01). CONCLUSION Hysteroscopic laser ablation represents a feasible and effective alternative for treating women with symptomatic submucous fibroids in the office setting. Further studies with larger sample size and longer follow-up periods are needed to validate this promising technique.Key messageThis pilot study shows that in-office hysteroscopic laser ablation (HLA) could be a feasible alternative to treat symptomatic submucous uterine fibroids by coagulating their core, reducing their size and vascularization.
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Affiliation(s)
- S G Vitale
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - O Moore
- Department of Obstetrics and Gynecology, Laniado University Hospital, Netanya, Israel
- Adelson School of Medicine, Ariel University, Ariel, Israel
| | - G Riemma
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - J Carugno
- Minimally Invasive Gynecology Unit, Obstetrics, Gynecology and Reproductive Sciences Department, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - M L Yarto
- Department of Obstetrics and Gynecology, Del Mar University Hospital, Barcelona, Spain
| | - S Haimovich
- Department of Obstetrics and Gynecology, Laniado University Hospital, Netanya, Israel
- Adelson School of Medicine, Ariel University, Ariel, Israel
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25
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Sinha S, Agarwal M, Bhadani PP, Roy R, Sinha U. Development and validation of sonological classification and scoring system for uterine adenomyosis: A pilot study. F1000Res 2023; 11:1138. [PMID: 37867625 PMCID: PMC10587656 DOI: 10.12688/f1000research.125700.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2023] [Indexed: 10/24/2023] Open
Abstract
Background: Adenomyosis is a common disorder in women of reproductive age. The gold standard for diagnosis is histopathological examination of hysterectomy specimen. However, only a small percentage of women undergo surgery as treatment is primarily hormonal. Non-invasive methods of diagnosis include transvaginal sonography and magnetic resonance imaging. Patient management in adenomyosis is often based on ultrasonographic diagnosis alone, highlighting the importance of a uniform, reproducible, clinically relevant and validated sonological classification and scoring system. Although a few investigators have proposed classification and scoring system for diagnosis of adenomyosis, none of those have been validated yet. This study aimed to propose and validate a new sonological classification and scoring system for adenomyosis. Methods: This was a prospective observational pilot study. A new sonological classification and scoring system of adenomyosis was proposed based on topography, type, size and extent, which was validated by comparing the sonological reporting with histopathological reporting. The main outcome measures that were measured were rate of agreement (Cohen's kappa) between the findings of sonologist and pathologist; and diagnostic accuracy of the sonological classification of adenomyosis. Results: This pilot study included 30 women who underwent hysterectomy over a time period of one year with ultrasonographic diagnosis of adenomyosis. The rate of agreement (Cohen's kappa) between the findings of sonologist and pathologist showed substantial agreement (0.703) for topography and almost perfect agreement for type (0.896), extent (0.892) and size (0.898). Conclusions: Our newly proposed sonological classification and scoring system for adenomyosis is valid and can be used for clinical application in interpersonal communication between clinicians, to prognosticate patients about the disease severity, to assess the candidates for surgical management and in further studies to correlate with symptoms severity and effectiveness of medical therapies.
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Affiliation(s)
- Sudwita Sinha
- Obstetrics & Gynecology, AIIMS, PATNA, BIHAR, 801507, India
| | - Mukta Agarwal
- Obstetrics & Gynecology, AIIMS, PATNA, BIHAR, 801507, India
| | | | - Ria Roy
- Community and Family medicine, AIIMS, PATNA, Bihar, 801507, India
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Kontogiannis A, Matsas A, Valsami S, Livanou ME, Panoskaltsis T, Christopoulos P. Primary Hemostasis Disorders as a Cause of Heavy Menstrual Bleeding in Women of Reproductive Age. J Clin Med 2023; 12:5702. [PMID: 37685769 PMCID: PMC10488471 DOI: 10.3390/jcm12175702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 08/28/2023] [Accepted: 08/30/2023] [Indexed: 09/10/2023] Open
Abstract
Heavy menstrual bleeding (HMB) is a common clinical condition affecting adolescent and adult women and compromising their quality of life. Primary hemostasis disorders, affecting platelet plug formation, can be the underlying cause of HMB. They comprise a heterogeneous group of diseases with Von Willebrand disease (VWD) being the most commonly diagnosed; other disorders in this group that have been linked to HMB include (a) Glanzmann thrombasthenia, (b) Bernard-Soulier syndrome, (c) Hermansky-Pudlak syndrome, (d) immune thrombocytopenia (ITP), and (e) Ehlers-Danlos syndromes (EDS) and hypermobility spectrum disorders (HSD). Diagnosing these diseases can be challenging, as the basic laboratory investigations can be within the normal range. Thus, identification of specific clinical features and a thorough hematologic workup can be very important, providing the correct diagnosis. Proper diagnosis of the underlying disorder is important, as management may vary accordingly. Although disease-specific management guidelines exist for some of these disorders such as VWD and ITP, due to the rarity of most primary hemostasis disorders, the best approach for the management of HMB in these women remains elusive. The goal of this study was to create an informative, comprehensive review of the primary hemostasis disorders that have been linked to HMB. This study provides a summary of the basic published information regarding epidemiology, pathophysiology, clinical phenotype, diagnosis, and treatment of HMB in those diseases and serves as a reference guide for further reading.
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Affiliation(s)
- Athanasios Kontogiannis
- Second Department of Obstetrics and Gynecology, “Aretaieion” Hospital, Faculty of Medicine, National and Kapodistrian University of Athens, 115 28 Athens, Greece
| | - Alkis Matsas
- Second Department of Obstetrics and Gynecology, “Aretaieion” Hospital, Faculty of Medicine, National and Kapodistrian University of Athens, 115 28 Athens, Greece
| | - Serena Valsami
- Hematology Laboratory-Blood Bank, Aretaieion Hospital, National and Kapodistrian University of Athens, 115 28 Athens, Greece
| | - Maria Effrosyni Livanou
- Second Department of Obstetrics and Gynecology, “Aretaieion” Hospital, Faculty of Medicine, National and Kapodistrian University of Athens, 115 28 Athens, Greece
| | - Theodoros Panoskaltsis
- Second Department of Obstetrics and Gynecology, “Aretaieion” Hospital, Faculty of Medicine, National and Kapodistrian University of Athens, 115 28 Athens, Greece
| | - Panagiotis Christopoulos
- Second Department of Obstetrics and Gynecology, “Aretaieion” Hospital, Faculty of Medicine, National and Kapodistrian University of Athens, 115 28 Athens, Greece
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Kızılcan Çetin S, Aycan Z, Özsu E, Şıklar Z, Ceran A, Erişen Karaca S, Şenyazar G, Berberoğlu M. Evaluation of Abnormal Uterine Bleeding in Adolescents: Single Center Experience. J Clin Res Pediatr Endocrinol 2023; 15:230-237. [PMID: 36794870 PMCID: PMC10448548 DOI: 10.4274/jcrpe.galenos.2023.2022-10-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 02/04/2023] [Indexed: 02/17/2023] Open
Abstract
Objective Abnormal uterine bleeding (AUB) is the most common gynecologic complaint in adolescent girls. The aim of this study was to identify the diagnostic and management differences between those with/without heavy menstrual bleeding. Methods Retrospective data was collected from adolescents aged 10-19 years, diagnosed with AUB. Adolescents with known bleeding disorders at admission were excluded. All girls were classified according to the degree of anemia; group 1 had heavy bleeding [hemoglobin (Hb) <10 g/dL] and group 2 had moderate or mild bleeding (Hb >10 g/dL). Admission and follow-up characteristics were compared between the two groups. Results The cohort consisted of 79 girls with a mean age of 14.3±1.8 years and mean age of menarche of 11.9±1.4 years, with 85% experiencing menstrual irregularity in the two years after menarche, rising to 95.3% in group 1 (p<0.01). Anovulation was evident in 80% of the cohort. Of these 79 girls, 13 (16.5%) had polycystic ovary syndrome and two (2.5%) had structural anomalies (uterus didelphys). Three girls (group 1, n=2) had previously undiagnosed clotting factor VII deficiency; no other clotting deficiencies were diagnosed. Nineteen of 34 (56%) with personal (n=2)/family history of thrombosis had MTHFR mutation. None had venous thromboembolism during follow-up of >6 months. Conclusion The majority of AUB (85%) occurred in the first two years after menarche. A small proportion (3.8%) had undiagnosed clotting factor deficiency. The frequency of MTHFR mutation was 50% in girls with history of thrombosis; however this did not increase the risk of bleeding/thrombosis and so routine evaluation does not appear to be justified.
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Affiliation(s)
- Sirmen Kızılcan Çetin
- Ankara University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
| | - Zehra Aycan
- Ankara University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
- Ankara University Faculty of Medicine, Department of Adolescent Health, Ankara, Turkey
| | - Elif Özsu
- Ankara University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
| | - Zeynep Şıklar
- Ankara University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
| | - Ayşegül Ceran
- Ankara University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
| | - Seda Erişen Karaca
- Ankara University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
| | - Gizem Şenyazar
- Ankara University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
| | - Merih Berberoğlu
- Ankara University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
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Venturella R, Rechberger T, Zatik J, Wagman RB, Zhu E, Rakov VG, Petraglia F. Relugolix combination therapy in European women with symptomatic uterine fibroids: a subgroup analysis from the randomized phase 3 LIBERTY pivotal trials. Gynecol Endocrinol 2023; 39:2249107. [PMID: 37634528 DOI: 10.1080/09513590.2023.2249107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 07/31/2023] [Accepted: 08/09/2023] [Indexed: 08/29/2023] Open
Abstract
OBJECTIVE In the 24-week, phase 3 LIBERTY 1 (L1) and LIBERTY 2 (L2) trials, relugolix combination therapy (relugolix-CT (relugolix 40 mg, estradiol 1 mg, norethisterone acetate 0.5 mg)) reduced uterine fibroid (UF)-associated symptoms. This post hoc analysis assessed safety and efficacy of relugolix-CT in European women from L1/L2. METHODS Premenopausal women (aged 18-50 years) with UF-associated heavy menstrual bleeding (HMB) were randomized 1:1:1 in L1 (N = 388) and L2 (N = 382) to relugolix-CT or placebo for 24 weeks, or delayed relugolix-CT (relugolix 40 mg then relugolix-CT; 12 weeks each). Primary endpoint: proportion of responders (menstrual blood loss (MBL) <80 mL and reduction of ≥50% from baseline MBL volume) over the last 35 days of treatment. Secondary endpoints: MBL volume, amenorrhea, UF-associated pain, symptom severity, distress related to bleeding and pelvic discomfort, health-related quality of life (HRQoL). Safety endpoints included adverse event (AE) reporting and bone mineral density (BMD) assessment. RESULTS In European women from L1/L2 (N = 124, 16%), a significantly greater proportion of treatment responders was observed with relugolix-CT vs. placebo (85.4% vs. 19.1%, respectively; nominal p < .0001). There were statistically significant improvements with relugolix-CT vs. placebo for several secondary endpoints: reduction in MBL volume, amenorrhea rate, proportion achieving mild-to-no pain, reduction in symptom severity and distress from bleeding and pelvic discomfort, and improvement in HRQoL. Incidence of AEs and percentage changes in BMD from baseline to week 24 were similar for relugolix-CT and placebo. CONCLUSIONS In European women with UF and HMB, once-daily relugolix-CT vs. placebo improved UF-associated symptoms and preserved BMD.
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Affiliation(s)
- Roberta Venturella
- Department of Clinical and Experimental Medicine, Unit of Obstetrics and Gynecology, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Tomasz Rechberger
- Second Department of Gynecology, Medical University of Lublin, Lublin, Poland
| | - János Zatik
- Szent Anna Women's OB/GYN and Ultrasound Outpatient Clinic, Debrecen, Hungary
| | - Rachel B Wagman
- Clinical Research, Sumitomo Pharma America, Inc., Brisbane, CA, USA
| | - Emily Zhu
- Development Operation, Sumitomo Pharma America, Inc., Brisbane, CA, USA
| | | | - Felice Petraglia
- Department of Experimental, Clinical and Biomedical Sciences, Obstetrics and Gynecology, University of Florence, Careggi University Hospital, Florence, Italy
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29
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Henry C, Filoche S. Reflections on access to care for heavy menstrual bleeding: Past, present, and in times of the COVID-19 pandemic. Int J Gynaecol Obstet 2023; 162 Suppl 2:23-28. [PMID: 37538016 DOI: 10.1002/ijgo.14945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
The symptom of heavy menstrual bleeding (HMB) affects at least a quarter of reproductive-age menstruators. However, given the variance in diagnosing the underlying causes, barriers, and inequity in access to care for HMB, and therefore reporting of HMB, this figure is likely to be a gross underestimate. HMB can have a detrimental impact on quality of life. From the limited reports available it is estimated that around 50%-80% of people with HMB do not seek care for this debilitating symptom, and for those that do, it may take years until the first treatment action. Almost half of those with HMB believe their condition is unworthy of treatment, that there is no treatment available, or that it is "normal". The term "medical gaslighting" has recently been used to describe how healthcare professionals disregard people's symptoms. This has the ensuing effect of negatively compounding self-doubt and embarrassment around menstrual bleeding, creating a cycle of diminished experience inhibiting further seeking of care. There is a scarcity of intervention studies informing increased access to care. Multilevel approaches are needed to increase access to care and support for those with HMB. During the COVID-19 global pandemic, barriers to care access and support for HMB have been exacerbated and, given the significant pressures that this pandemic has placed on healthcare services worldwide, it will take many years to recover. In the meantime, it is crucial to ensure that medically "benign" conditions such as the symptom of HMB are not overlooked.
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Affiliation(s)
- Claire Henry
- Department of Obstetrics, Gynecology, and Women's Health, University of Otago, Wellington, New Zealand
| | - Sara Filoche
- Department of Obstetrics, Gynecology, and Women's Health, University of Otago, Wellington, New Zealand
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Abbott JA, Munro MG. Evidence gaps for the global problem of iron deficiency and iron deficiency anemia in women and girls of reproductive age. Int J Gynaecol Obstet 2023; 162 Suppl 2:89-92. [PMID: 37538009 DOI: 10.1002/ijgo.14952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
The symptom of heavy menstrual bleeding and the frequently associated condition of iron deficiency (ID) individually and collectively adversely impact the lives of women and girls of reproductive age in various ways. The insidious but sometimes profound effects of periconceptual ID on the developing fetus may continue throughout the individual's life with consequences that are also felt by families, friends, and society at large. Unfortunately, in most instances, current healthcare policies are not designed to address the plethora of issues in a fashion that will result in meaningful improvement in health and other outcomes that affect both individuals and society. Identification and prioritization of the many evidence gaps will be an essential component of the strategy for change. This article identifies and describes the evidence gaps and provides direction for investigators and those involved in healthcare policy.
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Affiliation(s)
- Jason A Abbott
- Department of Obstetrics and Gynecology, School of Clinical Medicine, UNSW Sydney, Sydney, New South Wales, Australia
| | - Malcolm G Munro
- Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, University of California, Los Angles, Los Angeles, California, USA
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Ragni MV, Rothenberger SD, Feldman R, Nance D, Leavitt AD, Malec L, Kulkarni R, Sidonio R, Kraut E, Lasky J, Pruthi R, Angelini D, Philipp C, Hwang N, Wheeler AP, Seaman C, Machin N, Xavier F, Meyer M, Bellissimo D, Humphreys G, Smith KJ, Merricks EP, Nichols TC, Ivanco D, Vehec D, Koerbel G, Althouse AD. Recombinant von Willebrand factor and tranexamic acid for heavy menstrual bleeding in patients with mild and moderate von Willebrand disease in the USA (VWDMin): a phase 3, open-label, randomised, crossover trial. Lancet Haematol 2023; 10:e612-e623. [PMID: 37385272 PMCID: PMC10528809 DOI: 10.1016/s2352-3026(23)00119-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 04/25/2023] [Accepted: 04/27/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Heavy menstrual bleeding occurs in 80% of women with von Willebrand disease and is associated with iron deficiency and poor response to current therapies. International guidelines indicate low certainty regarding effectiveness of hormonal therapy and tranexamic acid. Although von Willebrand factor (VWF) concentrate is approved for bleeds, no prospective trials guide its use in heavy menstrual bleeding. We aimed to compare recombinant VWF with tranexamic acid for reducing heavy menstrual bleeding in patients with von Willebrand disease. METHODS VWDMin, a phase 3, open-label, randomised crossover trial, was done in 13 haemophilia treatment centres in the USA. Female patients aged 13-45 years with mild or moderate von Willebrand disease, defined as VWF ristocetin cofactor less than 0·50 IU/mL, and heavy menstrual bleeding, defined as a pictorial blood assessment chart (PBAC) score more than 100 in one of the past two cycles were eligible for enrolment. Participants were randomly assigned (1:1) to two consecutive cycles each of intravenous recombinant VWF, 40 IU/kg over 5-10 min on day 1, and oral tranexamic acid 1300 mg three times daily on days 1-5, the order determined by randomisation. The primary outcome was a 40-point reduction in PBAC score by day 5 after two cycles of treatment. Efficacy and safety were analysed in all patients with any post-baseline PBAC scores. The trial was stopped early due to slow recruitment on Feb 15, 2022, by a data safety monitoring board request, and was registered at ClinicalTrials.gov, NCT02606045. FINDINGS Between Feb 12, 2019, and Nov 16, 2021, 39 patients were enrolled, 36 of whom completed the trial (17 received recombinant VWF then tranexamic acid and 19 received tranexamic acid then recombinant VWF). At the time of this unplanned interim analysis (data cutoff Jan 27, 2022), median follow-up was 23·97 weeks (IQR 21·81-28·14). The primary endpoint was not met, neither treatment corrected PBAC score to the normal range. Median PBAC score was significantly lower after two cycles with tranexamic acid than with recombinant VWF (146 [95% CI 117-199] vs 213 [152-298]; adjusted mean treatment difference 46 [95% CI 2-90]; p=0·039). There were no serious adverse events or treatment-related deaths and no grade 3-4 adverse events. The most common grade 1-2 adverse events were mucosal bleeding (four [6%] patients during tranexamic acid treatment vs zero during recombinant VWF treatment) and other bleeding (four [6%] vs two [3%]). INTERPRETATION These interim data suggest that recombinant VWF is not superior to tranexamic acid in reducing heavy menstrual bleeding in patients with mild or moderate von Willebrand disease. These findings support discussion of treatment options for heavy menstrual bleeding with patients based on their preferences and lived experience. FUNDING National Heart Lung Blood Institute (National Institutes of Health).
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Affiliation(s)
- Margaret V Ragni
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Hemophilia Center of Western Pennsylvania, Pittsburgh, PA, USA.
| | - Scott D Rothenberger
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robert Feldman
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | - Lynn Malec
- Versiti Blood Research Institute, Milwaukee, WI, USA
| | | | | | - Eric Kraut
- The Ohio State University, Columbus, OH, USA
| | | | | | | | | | - Nina Hwang
- Center for Inherited Bleeding Disorders, Orange, CA, USA
| | | | - Craig Seaman
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Hemophilia Center of Western Pennsylvania, Pittsburgh, PA, USA
| | - Nicoletta Machin
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Hemophilia Center of Western Pennsylvania, Pittsburgh, PA, USA
| | - Frederico Xavier
- Hemophilia Center of Western Pennsylvania, Pittsburgh, PA, USA; Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Michael Meyer
- Vitalant Coagulation Laboratory, Pittsburgh, PA, USA
| | - Daniel Bellissimo
- Department of Pathology, Magee Women's Hospital Clinical Genomics Laboratory, Pittsburgh, PA, USA
| | - Gregory Humphreys
- Department of Pathology, Magee Women's Hospital Clinical Genomics Laboratory, Pittsburgh, PA, USA
| | - Kenneth J Smith
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA, USA
| | - Elizabeth P Merricks
- Department of Pathology and Laboratory Medicine and the UNC Blood Research Center, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Timothy C Nichols
- Department of Pathology and Laboratory Medicine and the UNC Blood Research Center, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Dana Ivanco
- Hemophilia Center of Western Pennsylvania, Pittsburgh, PA, USA
| | - Deborah Vehec
- Hemophilia Center of Western Pennsylvania, Pittsburgh, PA, USA
| | - Glory Koerbel
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA, USA
| | - Andrew D Althouse
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA, USA
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Munro MG. Heavy menstrual bleeding, iron deficiency, and iron deficiency anemia: Framing the issue. Int J Gynaecol Obstet 2023; 162 Suppl 2:7-13. [PMID: 37538011 DOI: 10.1002/ijgo.14943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
For girls and women in their reproductive years, the symptom of heavy menstrual bleeding (HMB) is the most common cause of iron deficiency (ID), including the extreme manifestation of iron deficiency anemia (IDA). It is recognized that these two clinical entities are not only ubiquitous, but their interrelationship is poorly appreciated and frequently normalized by society, healthcare providers, and affected girls and women themselves. Both HMB and ID/IDA adversely impact quality of life-HMB during the episodes of bleeding and ID daily as long as the ID exists. These combined issues undermine the lives of reproductive-aged girls and women of all ages, from menarche to menopause. At the same time, pervading culture and the often insidious nature of these disorders frequently lead to societal normalization, including by healthcare professionals. The effects on cognitive function as well as 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 suggesting that ID, even in early pregnancy, may adversely impact fetal neurodevelopment with enduring effects on a spectrum of cognitive and psychological disorders-effects that can have widespread impacts on society. Collectively, this critically important evidence begs the implementation of diagnostic and management guidelines aimed at identifying iron-deficient girls and women, repleting their iron stores, and, when present, effectively treating the most common reason for the problem-the various causes of the symptom of HMB.
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Affiliation(s)
- Malcolm G Munro
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
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Abstract
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.
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Affiliation(s)
- Varsha Jain
- Centre for Reproductive HealthUniversity of EdinburghEdinburgh, ScotlandUK
| | - Malcolm G. Munro
- Department of Obstetrics and GynecologyDavid Geffen School of Medicine at UCLALos AngelesCaliforniaUSA
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Derman RJ, Patted A. Overview of iron deficiency and iron deficiency anemia in women and girls of reproductive age. Int J Gynaecol Obstet 2023; 162 Suppl 2:78-82. [PMID: 37538013 DOI: 10.1002/ijgo.14950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Over 50% of pregnant women are anemic and the majority of these are iron deficient. Micronutrient deficiency, the symptom of heavy menstrual bleeding in nonpregnant individuals, and loss of blood associated with pregnancy and obstetric delivery contribute to iron deficiency (ID). Poor outcomes with low maternal iron can affect not only the pregnancy but can also have major bearings on the offspring. Correction of ID and iron deficiency anemia (IDA) in pregnant and prepregnant populations with single-dose intravenous iron supplementation may offer improved outcomes. A harmonization process that incorporates all major randomized controlled trials studying the use of single-dose IV iron compared with oral iron may suggest actions for changing the global trajectory of ID/IDA for women and girls of reproductive age.
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Affiliation(s)
- Richard J Derman
- Office of Global Affairs, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Anmol Patted
- Office of Global Affairs, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Munro MG, Critchley HOD. Our path from abnormal uterine bleeding and iron deficiency to impaired fetal development: A long and winding road. Int J Gynaecol Obstet 2023; 162 Suppl 2:3-6. [PMID: 37538012 DOI: 10.1002/ijgo.14942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
SynopsisAbnormal 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.
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Affiliation(s)
- Malcolm G Munro
- Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, The University of California, Los Angeles, Los Angeles, California, USA
- FIGO Committee on Menstrual Disorders and Related Health Impacts (MDRHI), London, UK
| | - Hilary O D Critchley
- FIGO Committee on Menstrual Disorders and Related Health Impacts (MDRHI), London, UK
- Centre for Reproductive Health, College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh, UK
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Munro MG, Mast AE, Powers JM, Kouides PA, O'Brien SH, Richards T, Lavin M, Levy BS. The relationship between heavy menstrual bleeding, iron deficiency, and iron deficiency anemia. Am J Obstet Gynecol 2023; 229:1-9. [PMID: 36706856 DOI: 10.1016/j.ajog.2023.01.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 01/09/2023] [Accepted: 01/14/2023] [Indexed: 01/26/2023]
Abstract
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.
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Affiliation(s)
- Malcolm G Munro
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA.
| | - Alan E Mast
- Versiti Blood Research Institute, Milwaukee, WI
| | - Jacquelyn M Powers
- Department of Pediatrics, Baylor College of Medicine, Houston TX; Cancer and Hematology Center, Texas Children's Hospital, Houston, TX
| | - Peter A Kouides
- Mary M. Gooley Hemophilia Center, Rochester, NY; University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Sarah H O'Brien
- Center for Health Equity and Outcomes Research and the Hemostasis and Thrombosis Center, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH; Division of Pediatric Hematology, Oncology & Blood and Marrow Transplant, Nationwide Children's Hospital, Columbus, OH
| | - Toby Richards
- Division of Surgery, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Australia
| | - Michelle Lavin
- National Coagulation Centre, St James' Hospital, Dublin, Ireland; Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Barbara S Levy
- Department of Obstetrics and Gynecology, University of California, San Diego, San Diego, CA; Department of Obstetrics and Gynecology, The George Washington University, Washington, DC
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Porcaro G, Bilotta G, Capoccia E, Bezerra Espinola MS, Aragona C. D-Chiro-Inositol in Endometrial Hyperplasia: A Pilot Study. Int J Mol Sci 2023; 24:10080. [PMID: 37373229 DOI: 10.3390/ijms241210080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/08/2023] [Accepted: 06/10/2023] [Indexed: 06/29/2023] Open
Abstract
Endometrial hyperplasia is a threatening pathology driven by unopposed estrogen stimulus. Moreover, insulin may act on the endometrium, prompting further growth. We aimed at assessing whether D-chiro-Inositol, an insulin sensitizer with estrogen-lowering properties, might improve the condition of patients with simple endometrial hyperplasia without atypia. We enrolled women with simple endometrial hyperplasia without atypia and related symptoms, including abnormal uterine bleeding. We treated the patients with one tablet per day, containing 600 mg of D-chiro-inositol for six months. Patients underwent ultrasound to assess the thickness of the endometrium at baseline, after three months, and at the end of this study. Endometrial thickness went from 10.82 ± 1.15 mm to 8.00 ± 0.81 mm after three months (p < 0.001) and to 6.9 ± 1.06 mm after six months (p < 0.001 versus baseline; p < 0.001 versus three months). D-chiro-inositol treatment also improved heavy menstrual bleeding and the length of menstruation. Despite the fact that our data should be validated in larger studies with appropriate control groups, our promising results support the hypothesis that D-chiro-inositol may represent a useful treatment in the case of endometrial hyperplasia without atypia.
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Affiliation(s)
- Giuseppina Porcaro
- Women's Health Centre, USL Umbria 2, 05100 Terni, Italy
- The Experts Group on Inositol in Basic and Clinical Research (EGOI), 00156 Rome, Italy
| | | | | | - Maria Salomé Bezerra Espinola
- The Experts Group on Inositol in Basic and Clinical Research (EGOI), 00156 Rome, Italy
- Systems Biology Group Lab, 00161 Rome, Italy
| | - Cesare Aragona
- The Experts Group on Inositol in Basic and Clinical Research (EGOI), 00156 Rome, Italy
- Systems Biology Group Lab, 00161 Rome, Italy
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Silva Filho AL, Catherino WH, Estrade JP, Koga K, Singh SS, Vannuccini S, Yang X, Lahav A, Caetano C, Calaf J. The HOPE study: evaluating the impact of an online educational resource for heavy menstrual bleeding on the patient-physician dynamic. Women Health 2023:1-13. [PMID: 37291687 DOI: 10.1080/03630242.2023.2220806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The Heavy menstrual bleeding: Evidence-based Learning for best Practice (HELP) Group developed an educational website about heavy menstrual bleeding (HMB). The "HMB improving Outcomes with Patient counseling and Education" (HOPE) project examined the website's impact on women's knowledge, confidence, and consultations with healthcare providers (HCPs). HOPE was a quantitative online survey of gynecologists and women with HMB in Brazil. After an initial consultation, patients had unlimited access to the website and completed a survey. HCPs also completed a survey about the sconsultation. After a second consultation, HCPs and patients completed another survey. HCP surveys assessed their perception of patients' awareness, understanding, and willingness to discuss HMB. Patient surveys assessed their knowledge, experience, and confidence in discussing HMB. Forty HCPs recruited 400 women with HMB. Based on HCP perceptions at the first consultation, 18 percent of patients had "good knowledge" or "very good knowledge" of HMB, increasing to 69 percent after patients had visited the website. Before and after visiting the website, 34 percent and 69 percent of patients, respectively, regarded their HMB knowledge as "goo.d" Additionally, 17 percent of women reported their anxiety as "highest" during the first consultation; this decreased to 7 percent during the second consultation. After visiting the HELP website, patients' knowledge of HMB improved and they were less anxious.
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Affiliation(s)
| | - William H Catherino
- Research Division, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | | | - Kaori Koga
- Department of Obstetrics and Gynecology, Chiba University and University of Tokyo, Tokyo, Japan
| | - Sukhbir S Singh
- Obstetrics and Gynecology, University of Ottawa, Ottawa, Canada
| | - Silvia Vannuccini
- Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| | - Xin Yang
- Gynecology, Peking University People's Hospital, Beijing, China
| | | | | | - Joaquim Calaf
- Hospital Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
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Dutton B, Kai J. Women's experiences of heavy menstrual bleeding and medical treatment: a qualitative study in primary care. Br J Gen Pract 2023; 73:e294-e301. [PMID: 36997220 PMCID: PMC9997654 DOI: 10.3399/bjgp.2022.0460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 11/15/2022] [Indexed: 04/01/2023] Open
Abstract
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.
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Affiliation(s)
- Brittany Dutton
- Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham
| | - Joe Kai
- Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham
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Nelson JM, Compton SD, Farahzad MM, Winfrey OK, Rosen MW. The relationship between estrogen and subsequent growth restriction among adolescents with heavy menstrual bleeding at menarche. J Pediatr Endocrinol Metab 2023; 36:255-260. [PMID: 36727420 DOI: 10.1515/jpem-2022-0536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 01/15/2023] [Indexed: 02/03/2023]
Abstract
OBJECTIVES We sought to evaluate the impact of estrogen-containing treatment for heavy menstrual bleeding (HMB) on subsequent height compared to progesterone-only or non-hormonal treatment when initiated at menarche. METHODS We performed a retrospective chart review of adolescent females aged 10-15 years who presented to an institution-affiliated outpatient, inpatient, or emergency setting for management of HMB within three months of menarche. Growth records over a 2 year period starting at menarche were recorded, and comparisons made among patients treated with 1) estrogen, 2) progesterone, and 3) non-hormonal methods (controls). Groups were compared using bivariate analysis with Chi-square or Fisher's exact test and linear regression. RESULTS In an analysis of 80 patients at 24 months, the mean increase in height from menarche was 6.4 cm among controls (n=54), 7.2 cm among the progesterone-only group (n=10), and 3.8 cm among the estrogen group (n=16). The estrogen group's increase in height was significantly lower than the control group's, by a mean of 1.8 cm (p=0.04). Change in height did not differ significantly between the progesterone and control groups (p=0.87). Additionally, for every year younger at menarche, there was 1 fewer cm of growth (change in height) at 24 months after menarche (p<0.002). CONCLUSIONS Estrogen-containing treatment for HMB initiated within three months of menarche was associated with reduced growth at 24 months compared to progesterone-only or non-hormonal methods. The clinical applicability of the estrogen group's 1.8 cm absolute reduction in height may have considerable significance for those who are shorter at baseline.
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Affiliation(s)
- Jessie M Nelson
- Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Sarah D Compton
- Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Mina M Farahzad
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Olivia K Winfrey
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Monica W Rosen
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
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Laffan M, Benson G, Farrelly C, Gomez K, Jones A, Maclean R, O'Donnell J, Lavin M. An expert consensus to define how higher standards of equitable care for von Willebrand disease can be achieved in the UK and Republic of Ireland. Haemophilia 2023; 29:819-826. [PMID: 36877609 DOI: 10.1111/hae.14765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/27/2023] [Accepted: 02/09/2023] [Indexed: 03/07/2023]
Abstract
INTRODUCTION Von Willebrand Disease (VWD) is the most common inherited bleeding disorder. However, recognition of the disease by both the public and healthcare professionals lags behind that of other bleeding disorders, leading to delays in diagnosis and treatment for patients. Updated national guidelines are needed to highlight an appropriate pathway for managing VWD patients in a timelier manner. AIM To identify ways in which care for VWD can be achieved on a more equitable basis. METHODS Using a modified Delphi approach, a panel of VWD experts developed 29 statements across five key themes. These were used to form an online survey that was distributed to healthcare professionals involved in VWD care across the UK and Republic of Ireland (ROI). Stopping criteria comprised 50 responses received, a 3-month window for response (February-April 2022) and 90% of statements passing consensus threshold. Threshold for consensus for each statement was agreed at 75%. RESULTS A total of 66 responses were analysed with 29/29 statements achieving consensus of which 27 attained ≥90% agreement. From the high degree of consensus, eight recommendations were derived regarding how detection and management of VWD can be improved to provide equity of care between men and women. CONCLUSION Implementation of these eight recommendations across the VWD pathway has the potential to raise the standard of care for patients in the UK and ROI by reducing delays to diagnosis and treatment initiation.
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Affiliation(s)
- Mike Laffan
- Centre for Haematology, Imperial College London, London, UK
| | - Gary Benson
- NI Haemophilia Comprehensive Care Centre, Belfast City Hospital, Belfast, UK
| | | | - Keith Gomez
- Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London, UK
| | | | | | - James O'Donnell
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, UK.,National Coagulation Centre, St James's Hospital, Dublin, UK
| | - Michelle Lavin
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, UK.,National Coagulation Centre, St James's Hospital, Dublin, UK
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Hancock JM, Escobar MA. An evaluation of von Willebrand factor (recombinant) therapy for adult patients living with severe type 3 von Willebrand disease. Expert Rev Hematol 2023; 16:157-161. [PMID: 36861346 DOI: 10.1080/17474086.2023.2184339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
INTRODUCTION Von Willebrand Factor (VWF) containing concentrates have been used for the treatment of von Willebrand Disease (VWD) for many years. Recently, however, a novel recombinant VWF (rVWF or vonicog alpha, VONVENDI [US], VEYVONDI [Europe]) has arrived to the market for the treatment of VWD. Initially, rVWF was approved by the U.S. Food and Drug Administration (FDA) for the on-demand treatment and control of bleeding episodes and for the perioperative management of bleeding for patients with VWD. More recently, however, the FDA has approved rVWF for routine prophylaxis to prevent bleeding episodes for those patients with severe type 3 VWD receiving on-demand therapy. AREAS COVERED This review will focus on recent phase III trial results from NCT02973087 regarding the use of long-term routine twice weekly prophylaxis with rVWF for the prevention of bleed events in patients with severe type 3 VWD. EXPERT OPINION A novel rVWF concentrate may have greater hemostatic potential over prior plasma-derived VWF concentrates and is now FDA approved for use in routine prophylaxis for patients with severe type 3 VWD in the United States. This greater hemostatic potential may be due to the presence of ultra-large VWF multimers and a more favorable high-molecular-weight multimer pattern compared to prior pdVWF concentrates.
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Affiliation(s)
- John M Hancock
- Gulf States Hemophilia and Thrombophilia Center, the University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Miguel A Escobar
- Gulf States Hemophilia and Thrombophilia Center, the University of Texas Health Science Center at Houston, Houston, Texas, USA
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McKain L, Edsall K, Dufour R, Lickert C. Treatment Patterns in Patients with Uterine Fibroids With and Without a Diagnosis of Heavy Menstrual Bleeding: Results from a Large U.S. Claims Database. J Womens Health (Larchmt) 2023; 32:332-340. [PMID: 36413048 PMCID: PMC9993160 DOI: 10.1089/jwh.2022.0056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background: This retrospective database analysis describes clinical characteristics and treatment patterns of U.S. women with a diagnosis for uterine fibroids (UF), both with and without heavy menstrual bleeding (HMB). Materials and Methods: Two cohorts aged 18-50 years with an incident UF diagnosis, comprising women with and without claims for HMB (UF-HMB and UF-only), were identified from the IQVIA PharMetrics® Plus database (January 1, 2010-December 31, 2019). The index date was the first UF claim following diagnosis; treatment patterns were documented for postindex years 1 and 2 and the full duration of postindex follow-up. Also identified were claims for symptoms or signs potentially associated with UF. Outcomes were the proportion of patients treated with pharmacologic therapies of interest and gynecologic procedures. Logistic regression was used to identify factors associated with postdiagnosis hysterectomy and hormonal therapy. Results: A total of 66,313 (71.8%) women were included in the UF-HMB cohort (mean age [standard deviation]) 42.6 [5.4] years), and 26,068 (28.2%) in the UF-only cohort (41.8 [6.3]). Median follow-up was ∼4 years. Pain was the most common symptom (42.7% in patients with UF-HMB and 36.6% with UF-only); also common were abnormal bleeding (15.6%, 11.5%) and fatigue (22.2%, 15.5%). Within 1 year of UF diagnosis, 28.8% and 49.2% of women with UF-HMB and UF-only, respectively, had no claims for relevant pharmacologic or surgical treatment. In logistic regression, multiple factors were associated with a higher likelihood of receiving hysterectomy or hormonal therapy. Conclusions: Patients with UF-HMB were more likely to receive UF treatment, either surgical or pharmacologic, than women with UF-only. Apart from HMB, pain was the most commonly documented symptom of UF.
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Affiliation(s)
- Laura McKain
- Medical Affairs, Myovant Sciences, Inc., Brisbane, California, USA
| | - Kaitlyn Edsall
- Life Sciences Practice, Charles River Associates, Boston, Massachusetts, USA
| | - Robert Dufour
- Medical Affairs, Myovant Sciences, Inc., Brisbane, California, USA
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Baldwin MK, Ahmadzia HK, Bartlett DL, Bensen-Kennedy D, Desai V, Haley KM, Herman-Hilker SL, Kilgore AM, Kulkarni R, Lavin M, Luckey S, Matteson KA, Paulyson-Nuñez K, Philipp CS, Ragosta S, Rosen K, Rotellini D, Weyand AC. Building the foundation for a community-generated national research blueprint for inherited bleeding disorders: research to advance the health of people with inherited bleeding disorders with the potential to menstruate. Expert Rev Hematol 2023; 16:71-86. [PMID: 36920864 PMCID: PMC10020871 DOI: 10.1080/17474086.2023.2175660] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 01/30/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND People who have or had the potential to menstruate (PPM) with inherited bleeding disorders (BD) face particular challenges receiving appropriate diagnosis and care and participating in research. As part of an initiative to create a National Research Blueprint for future decades of research, the National Hemophilia Foundation (NHF) and American Thrombosis and Hemostasis Network conducted extensive all-stakeholder consultations to identify the priorities of PPM with inherited BDs and those who care for them. RESEARCH DESIGN AND METHODS Working group (WG) 4 of the NHF State of the Science Research Summit distilled community-identified priorities for PPM with inherited BDs into concrete research questions and scored their feasibility, impact, and risk. RESULTS WG4 identified important gaps in the foundational knowledge upon which to base optimal diagnosis and care for PPM with inherited BDs. They defined 44 top-priority research questions concerning lifespan sex biology, pregnancy and the post-partum context, uterine physiology and bleeding, bone and joint health, health care delivery, and patient-reported outcomes and quality-of-life. CONCLUSIONS The needs of PPM will best be advanced with research designed across the spectrum of sex and gender biology, with methodologies and outcome measures tailored to this population, involving them throughout.
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Affiliation(s)
- Maureen K. Baldwin
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon, USA
| | - Homa K. Ahmadzia
- Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | | | | | - Vidhi Desai
- CSL Behring, King of Prussia, Pennsylvania, USA
| | - Kristina M. Haley
- The Hemophilia Center, Oregon Health and Science University, Portland, Oregon, USA
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon, USA
| | - Sherry L. Herman-Hilker
- Hemophilia and Coagulation Disorders Program, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Roshni Kulkarni
- MSU Center of Bleeding and Clotting Disorders, Department Pediatrics and Human Development, Michigan State University, East Lansing, Michigan, USA
| | - Michelle Lavin
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
- National Coagulation Centre, St. James’s Hospital, Dublin, Ireland
| | - Shari Luckey
- Hemophilia Foundation of Michigan, Ypsilanti, Michigan, USA
| | - Kristen A. Matteson
- Department of Obstetrics and Gynecology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Kristin Paulyson-Nuñez
- Duke Health Women & Children’s Services, Duke University Health Systems, Durham, North Carolina, USA
| | - Claire S. Philipp
- Division of Hematology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | | | - Kimberly Rosen
- Bayer HealthCare Pharmaceuticals, Whippany, New Jersey, USA
| | | | - Angela C. Weyand
- Division of Pediatric Hematology and Oncology, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Black D. Diagnosis and medical management of abnormal premenopausal and postmenopausal bleeding. Climacteric 2023; 26:222-228. [PMID: 36847215 DOI: 10.1080/13697137.2023.2178893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
Abnormal uterine bleeding is a common reason for presentation to health-care providers: it is estimated that one woman in three will present to a care provider with abnormal uterine bleeding (AUB) during the reproductive years, and that at least one woman in 10 will experience postmenopausal bleeding. Although there are some variations in national guidelines for investigation, diagnosis and management of premenopausal AUB, there are far more areas of agreement than disagreement. A comprehensive literature search was undertaken to review national and international guidelines regarding investigation, diagnosis and management of AUB in both premenopausal and postmenopausal women. Areas of controversy are identified, and latest evidence reviewed. Although efforts to reduce hysterectomies for premenopausal AUB through medical management have largely been successful, there are areas where more research is necessary to guide optimal investigation and management. Many countries have well-defined guidelines for investigation and management of premenopausal AUB: there are fewer well-developed guidelines for investigation and management of postmenopausal bleeding. There is a paucity of evidence-based data on management of unscheduled bleeding on menopausal hormone therapy.
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Affiliation(s)
- D Black
- Department of Obstetrics, Gynecology and Reproductive Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
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Patel JP, Nzelu O, Roberts LN, Johns J, Ross J, Arya R. How do anticoagulants impact menstrual bleeding and quality of life? - The PERIOD study. Res Pract Thromb Haemost 2023; 7:100072. [PMID: 36861116 PMCID: PMC9969064 DOI: 10.1016/j.rpth.2023.100072] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 12/23/2022] [Accepted: 12/28/2022] [Indexed: 02/05/2023] Open
Abstract
Background There is increasing recognition that menstruating women prescribed anticoagulants experience heavy menstrual bleeding. Objectives The aim of this study is to report the extent of bleeding in menstruating women after commencing anticoagulants and the impact it has on their quality of life. Methods Women aged 18 to 50, initiated on anticoagulant therapy, were approached to take part in the study. In parallel, a control group of women was also recruited. Women were asked to complete the menstrual bleeding questionnaire and a pictorial blood assessment chart (PBAC) during their next 2 menstrual cycles. Differences between the control and anticoagulated group were compared. Significance was considered at < .05. Ethics committee approval: REC reference: 19/SW/0211. Results Fifty-seven women in the anticoagulation and 109 women in the control group returned their questionnaires. Women in the anticoagulated group reported an increase in the median length of their menstrual cycle from 5 to 6 days after commencing anticoagulation, compared to 5 days for women in the control group (P < .05). Anticoagulated women reported significantly higher PBAC scores as compared to the control group (P < .05), with two-thirds of women in the anticoagulation group reporting heavy menstrual bleeding. Women in the anticoagulation group reported worsening quality of life scores following the initiation of anticoagulation, compared with women in the control group (P < .05). Conclusion Heavy menstrual bleeding occurred in two-thirds of women commencing anticoagulants, who completed a PBAC, which had negative impact on their quality of life. Clinicians commencing anticoagulation therapy should be mindful of this, and recognized measures should be taken to help minimize this problem for menstruating individuals.
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Affiliation(s)
- Jignesh P. Patel
- King’s Thrombosis Centre, Department of Haematological Medicine, King’s College Hospital Foundation NHS Trust, UK,Institute of Pharmaceutical Science, Faculty of Life Sciences and Medicine, King’s College London, UK,Correspondence Jignesh P. Patel, Institute of Pharmaceutical Science, School of Cancer and Pharmaceutical Sciences, King’s College London, Franklin-Wilkins Building, Stamford Street, London SE1 5RS, UK.
| | - Obianuju Nzelu
- Department of Women’s Health, King’s College Hospital Foundation NHS Trust, UK
| | - Lara N. Roberts
- King’s Thrombosis Centre, Department of Haematological Medicine, King’s College Hospital Foundation NHS Trust, UK
| | - Jemma Johns
- Department of Women’s Health, King’s College Hospital Foundation NHS Trust, UK
| | - Jackie Ross
- Department of Women’s Health, King’s College Hospital Foundation NHS Trust, UK
| | - Roopen Arya
- King’s Thrombosis Centre, Department of Haematological Medicine, King’s College Hospital Foundation NHS Trust, UK
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Perelló-Capo J, Rius-Tarruella J, Andeyro-García M, Calaf-Alsina J. Sensitivity to Change of the SAMANTA Questionnaire, a Heavy Menstrual Bleeding Diagnostic Tool, After 1 Year of Hormonal Treatment. J Womens Health (Larchmt) 2023; 32:208-215. [PMID: 36576860 DOI: 10.1089/jwh.2022.0155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background: The validated SAMANTA questionnaire allows identification of women with heavy menstrual bleeding (HMB); that is, with excessive menstrual bleeding that interferes with quality of life (QoL). We assessed its value for monitoring HMB treatment in clinical practice. Material and Methods: This is a prospective observational study conducted between December 2018 and March 2021 in consecutively recruited women with HMB attending gynecologists' offices who started a hormonal treatment. Sociodemographic characteristics were recorded at enrollment. At baseline and month 12, we assessed the HMB (SAMANTA questionnaire), the global impression of menstrual bleeding severity in patients (PGI-S) and clinicians (CGI-S), and the QoL (SF36). At month 12, we assessed the global impression of menstrual bleeding change in patients (PGI-C) and clinicians (CGI-C). Changes in SAMANTA questionnaire score at month 12 were compared with the presence of amenorrhea and changes in blood loss, menstrual period duration, and PGI-S, PGI-C, CGI-S, and CGI-C. Results: The study included 371 women aged 41.2 ± 6.5 years, 87% of whom were using the levonorgestrel intrauterine system. The SAMANTA questionnaire score significantly decreased in 97.3% of women. The decrease was greater in women reporting a reduction in blood loss, shorter menstrual bleeding duration, or a strong improvement in menstrual bleeding severity (PGI-S and CGI-S) or amount (PGI-C and CGI-C) (p < 0.001 for all), but not amenorrhea. SF-36 domains improved significantly; changes being inversely associated with changes in the SAMANTA questionnaire score. Conclusions: The SAMANTA questionnaire seems a valuable tool for monitoring hormonal treatment for HMB. ClinicalTrials.gov identifier NCT03751800.
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Affiliation(s)
- Josep Perelló-Capo
- Department of Obstetrics and Gynecology, Hospital de Sant Pau, Barcelona, Spain.,Paediatrics, Obstetrics and Gynecology, and Preventive Medicine and Public Health Department, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | | | - Joaquim Calaf-Alsina
- Department of Obstetrics and Gynecology, Hospital de Sant Pau, Barcelona, Spain.,Paediatrics, Obstetrics and Gynecology, and Preventive Medicine and Public Health Department, Universitat Autònoma de Barcelona, Barcelona, Spain
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48
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Abou-Ismail MY, James PD, Flood VH, Connell NT. Beyond the guidelines: how we approach challenging scenarios in the diagnosis and management of von Willebrand disease. J Thromb Haemost 2023; 21:204-214. [PMID: 36700502 DOI: 10.1016/j.jtha.2022.11.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 11/28/2022] [Accepted: 11/30/2022] [Indexed: 01/26/2023]
Abstract
Although von Willebrand disease (VWD) is the most common inherited bleeding disorder, its diagnosis and management are often challenging. Clinical practice guidelines, developed through systematic review of the medical literature and considering the best available evidence, provide guidance for common clinical scenarios. However, in the clinical setting, patients often present with characteristics and nuances that may fall outside the realm of available evidence and guidelines, and hence, shared decision-making will be essential in the evaluation and management of these patients. The challenges in the diagnosis of VWD are mainly attributable to the heterogeneity of the disorder, limitations of laboratory assays, and the significant impact of various physiologic processes on von Willebrand factor. The impact of physiologic normalization of von Willebrand factor, which may occur in various settings such as pregnancy, inflammation, or aging, remains uncertain, as is the optimal management in these scenarios. Multidisciplinary and individualized care, based on evolving evidence supported by clinicians, patients, caregivers, and stakeholders, will be needed to ensure the highest quality care for those who live with VWD.
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Affiliation(s)
- Mouhamed Yazan Abou-Ismail
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Paula D James
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Veronica H Flood
- Versiti Blood Research Institute and Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Nathan T Connell
- Division of Hematology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.
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49
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Guo SW. The Role of Platelets in the Pathogenesis and Pathophysiology of Adenomyosis. J Clin Med 2023; 12. [PMID: 36769489 DOI: 10.3390/jcm12030842] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/04/2023] [Accepted: 01/11/2023] [Indexed: 01/24/2023] Open
Abstract
Widely viewed as an enigmatic disease, adenomyosis is a common gynecological disease with bewildering pathogenesis and pathophysiology. One defining hallmark of adenomyotic lesions is cyclic bleeding as in eutopic endometrium, yet bleeding is a quintessential trademark of tissue injury, which is invariably followed by tissue repair. Consequently, adenomyotic lesions resemble wounds. Following each bleeding episode, adenomyotic lesions undergo tissue repair, and, as such, platelets are the first responder that heralds the subsequent tissue repair. This repeated tissue injury and repair (ReTIAR) would elicit several key molecular events crucial for lesional progression, eventually leading to lesional fibrosis. Platelets interact with adenomyotic cells and actively participate in these events, promoting the lesional progression and fibrogenesis. Lesional fibrosis may also be propagated into their neighboring endometrial-myometrial interface and then to eutopic endometrium, impairing endometrial repair and causing heavy menstrual bleeding. Moreover, lesional progression may result in hyperinnervation and an enlarged uterus. In this review, the role of platelets in the pathogenesis, progression, and pathophysiology is reviewed, along with the therapeutic implication. In addition, I shall demonstrate how the notion of ReTIAR provides a much needed framework to tether to and piece together many seemingly unrelated findings and how it helps to make useful predictions.
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50
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Vitale SG, Della Corte L, Ciebiera M, Carugno J, Riemma G, Lasmar RB, Lasmar BP, Kahramanoglu I, Urman B, Mikuš M, De Angelis C, Török P, Angioni S. Hysteroscopic Endometrial Ablation: From Indications to Instrumentation and Techniques-A Call to Action. Diagnostics (Basel) 2023; 13:diagnostics13030339. [PMID: 36766443 PMCID: PMC9914843 DOI: 10.3390/diagnostics13030339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 01/15/2023] [Accepted: 01/16/2023] [Indexed: 01/19/2023] Open
Abstract
The development of minimally invasive techniques has led to the creation of innovative alternatives in cases where traditional methods are not applicable. In modern gynecology, hysteroscopy has become the gold standard for the evaluation and treatment of intrauterine pathology. Endometrial ablation (EA) is a procedure that uses different types of energy to destroy the endometrium and is currently used as an alternative technique in cases of heavy menstrual bleeding when medical treatment has failed and uterine preservation is desired. The aim of this review was to evaluate the feasibility, safety, and clinical outcomes of hysteroscopic EA as an alternative in patients with abnormal uterine bleeding. A detailed computerized search of the literature was performed in the main electronic databases (MEDLINE, EMBASE, Web of Science, PubMed, and Cochrane Library), from 1994 to June 2022, to evaluate the outcomes in patients with abnormal uterine bleeding (AUB) undergoing EA using hysteroscopic and non-hysteroscopic techniques. Only scientific publications in English were included. Twelve articles on the current use of endometrial ablation were included. Data on patient symptoms, tools used for EA, primary outcomes, and adverse events were recorded. EA should be considered an effective and safe approach in the management of patients with abnormal uterine bleeding caused by benign pathology, in whom medical treatment has failed or is contraindicated. Due to the lack of evidence, it would be interesting to determine whether EA would also have a role in the treatment of women with premalignant lesions, avoiding invasive surgical procedures or medical treatment in those patients for whom hysterectomy or the use of hormonal treatment is contraindicated.
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Affiliation(s)
- Salvatore Giovanni Vitale
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy
- Correspondence: ; Tel.: +39-3479354575
| | - Luigi Della Corte
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Via Pansini 5, 80131 Naples, Italy
| | - Michał Ciebiera
- Second Department of Obstetrics and Gynecology, Center of Postgraduate Medical Education, 00189 Warsaw, Poland
| | - Josè Carugno
- Minimally Invasive Gynecology Unit, Obstetrics, Gynecology and Reproductive Sciences Department, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
| | - Gaetano Riemma
- Obstetrics and Gynecology Unit, Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80128 Naples, Italy
| | - Ricardo Bassil Lasmar
- Department of Surgery and Specialities, Federal Fluminense University, Rio de Janeiro 24020-140, Brazil
| | - Bernardo Portugal Lasmar
- Department of Surgery and Specialities, Federal Fluminense University, Rio de Janeiro 24020-140, Brazil
| | - Ilker Kahramanoglu
- Department of Gynecologic Oncology, Emsey Hospital, 34912 Istanbul, Turkey
| | - Bulent Urman
- Department of Obstetrics and Gynecology, Koc University School of Medicine, 34010 Istanbul, Turkey
| | - Mislav Mikuš
- Department of Obstetrics and Gynecology, University Hospital Centre Zagreb, Petrova 13, 10000 Zagreb, Croatia
| | - Carlo De Angelis
- Department of Maternal and Child Health and Urological Sciences, “Sapienza“ University of Rome, 00185 Rome, Italy
| | - Péter Török
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Debrecen, H-4032 Debrecen, Hungary
| | - Stefano Angioni
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy
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