Abnormal uterine bleeding in reproductive-aged women

Efficacy of Metformin-Cabergoline Compared to Metformin Monotherapy for Management of PCOS With Hyperprolactinemia: A Systematic Review and Meta-analysis

Background

Metformin plays a major part in the treatment of polycystic ovarian syndrome .Trials are being conducted to compare the effectiveness of combination of metformin with cabergoline in the treatment of hyperprolactinemia and polycystic ovarian syndrome.

Objectives

The purpose of this study is to compare the effectiveness of metformin monotherapy and combination therapy with cabergoline versus metformin for the management of polycystic ovarian syndrome with hyperprolactinemia.

Methodology

An extensive search up until 31 May 2024 of electronic databases (PubMed, Registry of Controlled Clinical Trials, Web of Sciences, SCOPUS) to find pertinent studies. An analysis was conducted with both observational data and randomized clinical trials . To compute the standard mean difference, weighted mean difference, odds ratio, and 95% confidence interval, RevMan (v5.3) was utilized. Primary outcomes that were assessed included body-mass index, regular menstruation, weight change, prolactin, testosterone, and dehydroepiandrosterone-sulfate levels.

Results

Three randomized controlled trials and 1 observational study, taking a total patient population of n = 535, were part of our final analysis. Prolactin (SMD = -3.23 95% CI: (-4.90, -1.55)) and dehydroepiandrosterone-sulfate levels (SMD = -0.27 95% CI: (-0.52, -0.01)) were significantly lower in the metformin and cabergoline combination therapy group; monthly regularity was also significantly higher (OR = 3.07 95% CI: (2.09, 4.51)). Statistically, there was no significant difference in weight, body-mass index, or testosterone levels.

Conclusions

In the treatment of polycystic ovarian syndrome, the combination of metformin and cabergoline significantly lowers prolactin levels and encourages regular menstrual cycles. Although metformin has the potential to suppress testosterone levels, more investigation is required to determine how combination therapy affect dehydroepiandrosterone-sulfate and testosterone levels. It's interesting to note that while neither intervention had a substantial impact on weight or body-mass index, metformin and cabergoline combination therapy outperformed metformin monotherapy in terms of supporting regular menstrual cycles. Customized therapy approaches are essential, and large-scale trials involving a variety of groups are required to comprehend the safety and effectiveness of treatments.

Effect of norethisterone dose and duration in the management of abnormal uterine bleeding: a narrative review and case report

Abnormal uterine bleeding (AUB) is an acute/chronic variation in the normal menstrual cycle that affects adolescents, women of reproductive age and perimenopausal women. AUB affects approximately 3-30% of reproductive-aged women worldwide, and reduces their quality of life and productivity whilst increasing the overall healthcare burden. Its management requires thorough medical evaluation and individualized treatment. Depending on the severity and cause of AUB, its treatment ranges from lifestyle modifications and hormonal therapies to more invasive procedures or surgery. Although hormonal therapy is the preferred first-line measure in AUB, the available pharmacological options have various adverse effects. There exists a need for safer and more efficient treatment regimens with high patient compliance to effectively treat AUB. Norethisterone, also known as norethindrone, is a widely used synthetic analogue of progestogen. Controlled release formulations of norethisterone/ norethisterone acetate help maintain constant drug levels in the blood and exert minimal side-effects; therefore, they are promising therapeutic agents for effective AUB management. The present review summarizes the epidemiology and diagnosis of AUB, with a focus on the safety, efficacy and tolerability of norethisterone/ norethisterone acetate in AUB management. We also report a case of AUB in a 40-year-old woman, who was treated with NETA tablets. The treatment resulted in favourable outcomes, and patient satisfaction.

Abnormal uterine bleeding and its associated factors among reproductive-age women who visit the gynecology ward in Dilla University General Hospital, Southern Ethiopia, 2022

BACKGROUND

Abnormal uterine bleeding, a frequent gynecological problem among women of reproductive age, significantly affects their health and quality of life. Despite its problem, research on its extent and contributing factors in Ethiopia is scarce. Hence, this study is designed to determine the magnitude and factors associated with abnormal uterine bleeding among women visiting Dilla University General Hospital, Dilla, Ethiopia.

METHODS

A cross-sectional study design was conducted with 380 women of reproductive age at Dilla University General Hospital. A systematic sampling method was employed to select the participants for the study. A structured interview administered questionnaire and checklist were used to collect the data. Stata V.14 software was used for cleaning, coding, ensuring completeness and accuracy, and further analysis. Bivariate and multivariable logistic regression analyses were used. Finally, the variables that have a p-value of < 0.05 were considered statistically significant.

RESULTS

In this study, the magnitude of abnormal uterine bleeding was 24.21% (95% CI, 20.14-28.79). History of sexually transmitted disease [AOR = 1.44, 95% CI: (1.33, 4.75)], history of anemia [AOR = 3.92, 95% CI: (1.20, 12.74)]., history of alcohol consumption [AOR = 2.49, 95% CI: (1.22, 5.06)], and perceived stress level [AOR = 1.30, 95% CI: (1.15, 1.69)] were found to be significantly associated with abnormal uterine bleeding.

CONCLUSIONS

The magnitude of abnormal uterine bleeding was 24.2% in the study setting. Factors such as a history of sexually transmitted disease, anemia, alcohol consumption, and perceived stress level were identified as significant risk factors for abnormal uterine bleeding. Addressing these factors is crucial for management. Further research and interventions targeting these risks are needed to enhance health outcomes. The study provides valuable insights for future interventions.

A comparison of the effects of oral dydrogesterone and levonorgestrel-releasing intrauterine device on quality of life and sexual function in patients with abnormal uterine bleeding

OBJECTIVE

The purpose of this study is to compare the effects of cyclic oral dydrogesterone treatment and levonorgestrel-releasing intrauterine device (LNG_IUD) on quality of life (QoL) and sexual function in patients diagnosed with abnormal uterine bleeding (AUB).

STUDY DESIGN

The study was conducted at the University of Health Sciences Turkey Health Istanbul Kanuni Sultan Süleyman Training and Research Hospital, on 171 sexually active patients, aged 18-45, who were under a minimum of 6 months of treatment for AUB. 85 patients were treated with oral cyclic dydrogesterone, and 86 patients received LNG-IUD. Following a minimum of 6 months of treatment, these patients were recruited to the study and were asked to complete a 36-Item Short Form Survey (SF-36) and the Female Sexual Function Index (FSFI).

RESULTS

When the FSFI scores of the patients were compared, it was observed that the total FSFI score was significantly higher in the cyclic dydrogesterone group (p < 0.05). Likewise, it was observed that sexual desire, arousal, and lubrication domains were significantly higher in the cyclic dydrogesterone group (p < 0.05). No significant differences were found between the treatment groups in 7 out of the 8 dimensions of SF-36. The energy/vitality dimension was found to be significantly higher in the cyclic dydrogesterone group.

CONCLUSION

Total FSFI score, as well as sexual desire, arousal, and lubrication scores, were significantly higher in the cyclic dydrogesterone group compared to the LNG-IUD group indicating that cyclic dydrogesterone has a more positive impact on sexual function when compared to LNG-IUD.

Endometrial Receptivity During the Preimplantation Period: A Narrative Review

Endometrial receptivity is a complex and critical process fundamental to achieving a successful pregnancy. While researchers have made significant strides in understanding the underlying mechanisms governing endometrial receptivity, effective diagnostic and therapeutic strategies remain scarce. This review article aims to elucidate the various factors that contribute to endometrial receptivity, including the hormonal regulation and molecular mechanisms that govern this process, as well as potential biomarkers for assessing endometrial receptivity. One of the major challenges in identifying reliable biomarkers for endometrial receptivity is the intricate nature of the process itself. Nonetheless, recent advances in transcriptomic and proteomic technologies have identified several candidate biomarkers that could potentially enhance our ability to predict endometrial receptivity. Furthermore, emerging technologies such as single-cell RNA sequencing and mass spectrometry-based proteomics hold great promise for providing novel insights into the molecular mechanisms underlying endometrial receptivity. Despite the lack of reliable biomarkers, various therapeutic strategies have been proposed to improve endometrial receptivity. One promising approach involves the transplantation of mesenchymal stem cells (MSCs), which have been shown to increase endometrial thickness and receptivity in both animal models and clinical trials. Growth factors, cytokines, and exosomes derived from MSCs and other cell types may also have therapeutic potential for addressing endometrial dysfunction.

Effects of Levonorgestrel-Releasing Intrauterine Device Therapy on Ovarian Reserve in Menorrhagia

Objective This study aimed to investigate the effects of levonorgestrel-releasing intrauterine device (LNG-IUD) treatment on ovarian reserve in women of reproductive age diagnosed with menorrhagia. Methods This was a prospective controlled trial involving 50 women with menorrhagia and a control group comprising age-matched 50 healthy women. Women who satisfied the LNG group criteria underwent an endometrial pipelle biopsy and LNG-IUD insertion. Ovarian reserve tests were performed prior to and six months after LNG-IUD insertion in the LNG group cases. Results Follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), anti-Müllerian hormone (AMH), endometrial thickness (ET), total antral follicle count (AFC), and mean ovarian volume values before LNG-IUD insertion did not differ between the LNG and control groups. When the final measurements were compared, FSH, AMH, total AFC, and average ovarian volume increased (p=0.05, 0.046, 0.022, and 0.022, respectively), E2 and ET decreased (p=0.034 and 0.001, respectively) in the LNG group, while LH did not differ significantly between the groups (p=0.71). Conclusion We observed that LNG-IUD use effectively improves fertility capacity. In this study, LNG-IUD use in reproductive-age women diagnosed with menorrhagia decreased E2 levels, did not change LH levels, and increased FSH, AFC, and AMH levels.

International Harmonization of Nomenclature and Diagnostic Criteria (INHAND): Non-proliferative and Proliferative Lesions of the Non-human Primate (M. fascicularis)

The INHAND (International Harmonization of Nomenclature and Diagnostic Criteria for Lesions Project (www.toxpath.org/inhand.asp) is a joint initiative of the Societies of Toxicologic Pathology from Europe (ESTP), Great Britain (BSTP), Japan (JSTP) and North America (STP) to develop an internationally accepted nomenclature for proliferative and nonproliferative lesions in laboratory animals. The purpose of this publication is to provide a standardized nomenclature for classifying microscopic lesions observed in most tissues and organs from the nonhuman primate used in nonclinical safety studies. Some of the lesions are illustrated by color photomicrographs. The standardized nomenclature presented in this document is also available electronically on the internet (http://www.goreni.org/). Sources of material included histopathology databases from government, academia, and industrial laboratories throughout the world. Content includes spontaneous lesions as well as lesions induced by exposure to test materials. Relevant infectious and parasitic lesions are included as well. A widely accepted and utilized international harmonization of nomenclature for lesions in laboratory animals will provide a common language among regulatory and scientific research organizations in different countries and increase and enrich international exchanges of information among toxicologists and pathologists.

Disparities in Treatment Decisions for Abnormal Uterine Bleeding

Background: Abnormal uterine bleeding (AUB) affects ∼1.4 million women in the United States each year. This study sought to identify differences in treatment decisions for managing noncancer-related AUB. Materials and Methods: IRB approval was obtained. This retrospective study analyzed data for all women 21-60 years old, diagnosed with AUB from July 1, 2013 through June 30, 2017, in an Obstetrics and Gynecology residents' clinic serving mostly underinsured patients. Patients with a diagnosis of postmenopausal bleeding or any gynecologic cancer were excluded. Two multivariable logistic regression models were used to identify variables independently associated with receiving surgical (vs. medical) treatment and any (vs. no) treatment. Results: Of 2,154 patients with AUB, 1,705 women met all inclusion criteria and had complete data for analysis. In the model examining receipt of surgical (vs. medical) treatment, women ages 41-60 were 4.8 times more likely than women 21-40 years old to receive surgical treatment. Women designated as "Other" (non-White) race/ethnicity were 80.8% less likely than Black/African American patients to receive surgery. Body mass index (BMI) and insurance type were not independently associated with receiving surgical treatment. In the model examining any (vs. no) treatment, women ages 41-60 (vs. 21-40) and of unknown (vs. Black/African American) race/ethnicity were 69.6% and 50.8% less likely to receive any treatment, respectively. BMI and insurance status were not independently associated with receiving any treatment. Conclusion: Management of AUB differed significantly by age and race/ethnicity, but not BMI or insurance. Further investigation among larger diverse populations is warranted to test the generalizability of these findings.

Office Hysteroscopy as a Valid Tool for Diagnosis of Genital Tract Lesions in Females with Intact Hymen

Background

To evaluate the feasibility and applicability of using office hysteroscopy in women with intact hymen.

Methods

We recruited 836 patients with intact hymen with different indications who underwent diagnostic hysteroscopy without anesthesia in an outpatient setting from 2007 to 2016 at Chang Gung Memorial Hospital at Linkou.

Results

Patients' mean age was 35 ± 10.6 years (range 3-69 years). Most patients (86.4%) with postmenopausal bleeding had intrauterine lesions, and they were especially at high risk (50%) for endometrial hyperplasia or malignancy. Five hundred thirty (63.3%) patients had histologic findings confirming concordance between hysteroscopic and histologic findings. Submucosal myoma had the highest concordance (96.3%), whereas endometrial hyperplasia had the lowest concordance (50%). Forty-eight patients (5.7%) had endometrial hyperplasia, and 35 patients (4.2%) had endometrial malignancy. Two patients who were thought to have nonspecific endometrial thickening actually had endometrial pathology.

Conclusions

Hysteroscopy through vaginoscopic approach is feasible and well-tolerated in the patients with intact hymen. This outpatient procedure provides accurate evaluation of lesions of the genital tract and should be considered in patients without a history of intercourse.

The effect of frankincense (Boswellia serrata, oleoresin) and ginger (Zingiber officinale, rhizoma) on heavy menstrual bleeding: A randomized, placebo-controlled, clinical trial

OBJECTIVES

To evaluate the effect of frankincense (Boswellia serrata, oleoresin) and ginger (Zingiber officinale, rhizoma) as complementary treatments for heavy menstrual bleeding (HMB) among women of reproductive age.

DESIGN

Randomized, placebo-controlled, clinical trial.

SETTING

Gynecology outpatient clinics.

INTERVENTIONS

Patients with HMB (n = 102) were randomly assigned to three groups. All patients received ibuprofen (200 mg) and either frankincense (300 mg), ginger (300 mg), or a placebo, which contains 200 mg anhydrous lactose as the filling agent and was similar in appearance to the two other drugs. Patients received the medications three times a day for seven days of the menstrual cycle, starting from the first bleeding day and this was repeated for two consecutive menstrual cycles.

MAIN OUTCOME MEASURES

Amount and duration of menstrual bleeding and quality of life (QOL).

RESULTS

Duration of menstrual bleeding was decreased in the frankincense (-1.77 ± 2.47 days, P = 0.003) and ginger (-1.8 ± 1.79 days, P = 0.001) groups, but not in the placebo group (-0.52 ± 1.86 days, P = 0.42). Amount of menstrual bleeding was decreased in all (P < 0.05), with no difference among the study groups (P > 0.05). More improvement in QOL was observed in the frankincense (-25.7 ± 3.1; P < 0.001) and ginger (-29.2 ± 3.7: P < 0.001) groups compared to the placebo group (-15.07 ± 3.52; P < 0.001) and between the groups, differences were statistically significant (P = 0.02).

CONCLUSIONS

Ginger and frankincense seem to be effective complementary treatments for HMB. Further studies with a larger sample size and longer follow-up are warranted in this regard.

Being Reproductive

Women's reproductive health maintenance begins in the early years of growth and development. Routine care is the basis for early detection of menstrual dysfunction and delays or acceleration of physical development. Patients and their families may not address menstruation concerns because of the sensitive nature of the topic, the patient's self-conscious attitudes, and the parent's apprehension. Providers should be able to provide early detection of menstrual abnormalities, which may uncover underlying health concerns and structural abnormalities. Early intervention and treatment may accelerate or decelerate physical growth, preserve fertility, and promote healthy behaviors with decreased psychological stress for patients and families.

Efficacy of Combined Cabergoline and Metformin Compared to Metformin Alone on Cycle Regularity in Patients with Polycystic Ovarian Disease with Hyperprolactinemia: A Randomized Clinical Trial

PURPOSE

Polycystic ovarian syndrome (PCOS) is a common reproductive disorder. Increasing serum prolactin in these patients could be detected in both follicular and luteal phase of the normal and stimulated cycles. Hyperprolactinemia affects the hypothalamic-pituitary-ovarian axis causing anovulation and abnormal uterine bleeding. In this study, the efficacy of combined cabergoline and metformin therapy was compared to metformin therapy alone in patients with PCOS on the body mass index, androgen profile and menstrual cycle regulation.

METHODS

Two hundred and fifty patients with polycystic ovarian syndrome (PCOS) with increased serum prolactin were randomly allocated into two groups: group (1) received oral metformin tablet 1000 mg per day and cabergoline 0.5 g tablet weekly for 3 months as a case group, and group (2) received oral metformin tablet 1000 mg per day and a placebo tablet weekly for 3 months as the control group (n = 123). Body mass index (BMI), menstrual cycle regularity, serum testosterone, serum prolactin and dehydroepiandrosterone sulfate (DHEAS) level were compared before and after treatment in both groups.

RESULTS

There was significant decrease in body mass index and improvement of androgenic profile in both groups after treatment. In group (1), there was significant improvement in cycle regularity and significant decrease in serum prolactin level post-treatment.

CONCLUSIONS

The use of cabergoline in addition to metformin had more favorable effect on cycle regularity and prolactin level in patients with polycystic ovarian syndrome with hyperprolactinemia than the use of metformin alone.