Pathophysiology of abnormal uterine bleeding

Diagnosis and management of uterine fibroids: current trends and future strategies

Uterine fibroids (UFs), leiomyomas or myomas, are a type of malignancy that affects the smooth muscle of the uterus, and it is most commonly detected in women of reproductive age. Uterine fibroids are benign monoclonal growths that emerge from uterine smooth muscle cells (myometrium) as well as fibroblasts. Uterine fibroid symptoms include abnormal menstrual bleeding leading to anaemia, tiredness, chronic vaginal discharge, and pain during periods. Other symptoms include protrusion of the abdomen, pain during intercourse, dysfunctions of bladder/bowel leading to urinary incontinence/retention, pain, and constipation. It is also associated with reproductive issues like impaired fertility, conceiving complications, and adverse obstetric outcomes. It is the leading cause of gynaecological hospitalisation in the American subcontinent and a common reason for the hysterectomy. Twenty-five percent of the reproductive women experience the symptoms of uterine fibroids, and among them, around 25% require hospitalization due to the severity of the disease. The frequency of the disease remains underestimated as many women stay asymptomatic and symptoms appear gradually; therefore, the condition remains undiagnosed. The exact frequency of uterine fibroids varies depending on the diagnosis, and the population investigated; nonetheless, the incidence of uterine fibroids in reproductive women ranges from 5.4 percent to 77 percent. The uterine fibroid treatment included painkillers, supplementation with iron, vitamin D3, birth control, hormone therapy, gonadotropin-releasing hormone (GnRH) agonists, drugs modulating the estrogen receptors, and surgical removal of the fibroids. However, more research needed at the level of gene to get a keen insight and treat the disease efficiently.

Correlation between cytological and histopathological examination of the endometrium in abnormal uterine bleeding

Background:

Abnormal uterine bleeding (AUB) is a common problem for which women seek gynecological consultation. Endometrial aspiration cytology (EAC) is an acceptable and valuable diagnostic procedure for screening the endometrial status.

Materials and Methods:

Endometrial aspiration using a menstrual regulation (MR) syringe and a 4 mm Karman's cannula was performed just prior to D and C in 100 women presenting with AUB. Smears were reviewed for cytomorphological findings and were correlated with the histopathological findings. These findings were categorized as benign endometrium, endometrial hyperplasia, malignancy and inadequate smears.

Results:

Age of the patients ranged from 19 to 70 years. In our study, the accuracy in diagnosing benign conditions of endometrium, hyperplasia, and malignancy on aspiration cytology were 93.88%, 96.94% and 96.84%, respectively.

Conclusions:

Endometrial aspiration is an effective, useful and a minimally invasive procedure. With an experienced cytologist, it can be used routinely for the primary investigation of women with AUB, provided all the points of discrepancies are taken care of.

Abnormal uterine bleeding following lumbar epidural corticosteroid injections and facet medial branch blocks in both pre- and postmenopausal women: a case series

BACKGROUND

Epidural steroid injections (ESIs) are now increasing in popularity with regard to the management of chronic lumbar radiculopathy. While ESIs have been shown to be effective in relieving low back and radicular pain, adverse reactions have also been reported, notably abnormal vaginal bleeding.

OBJECTIVE

We present a case series of four women, both pre- and postmenopausal, with chronic lumbar radiculopathy and corresponding pathology who developed abnormal vaginal bleeding after receiving either ESIs or facet medial branch blocks (MBBs) for pain management. Setting.  University of California, Los Angeles.

PATIENTS

Four women, both pre- and postmenopausal.

CONCLUSIONS

We discuss the potential effects of corticosteroids on the hypothalamic-pituitary-ovarian axis and highlight our patients' risk factors for abnormal vaginal bleeding, both exogenous and endogenous, as well as focus on the technical approaches to corticosteroid administration utilized in our patients' procedures. We acknowledge that because this is a small case series, further prospective investigation is warranted regarding the above topics. Until then, it may be beneficial to consider whether patients, both pre- and postmenopausal, have risk factors for abnormal uterine bleeding prior to undergoing interventional pain management strategies, specifically ESI and MBB, and to inform all women upon consent that abnormal vaginal bleeding is a potential risk following procedures with corticosteroids.

Gonadotropin-releasing hormone analog combined with a low-dose oral contraceptive to treat heavy menstrual bleeding

OBJECTIVE

To compare the effects of low-dose oral contraceptives used alone and in combination with a gonadotropin-releasing hormone (GnRH) analog to treat heavy menstrual bleeding.

METHODS

Fifty-eight patients with heavy menstrual bleeding were prospectively randomized into two treatment groups to receive either a low-dose oral contraceptive alone (group 1), or combined with a GnRH analog (group 2) for 6 months. The patients' hormonal profiles, and hemoglobin and hematocrit levels were measured at the beginning and at the end of the treatment period.

RESULTS

Hemoglobin and hematocrit levels significantly improved in both groups after 6 months of treatment (P<0.05 and P<0.01, respectively). Even in the first month of the study, the number of pads used and the duration of menstruation were significantly decreased in both groups and markedly lower in group 2 (P<0.01).

CONCLUSION

The addition of a GnRH analog to low-dose oral contraceptive treatment for heavy menstrual bleeding resulted in better control of vaginal bleeding, even in the first month of therapy.

Medical Therapies for Chronic Menorrhagia

An estimated 10%-30% of menstruating women experience menorrhagia at some time during their reproductive lives. Acute menorrhagia may present as an emergency requiring prompt medical or surgical intervention. Chronic menorrhagia affects a woman's quality of life in her work, family, and social interactions. Medical management is the first line of therapy for chronic menorrhagia. Agents that have been used to treat menorrhagia include iron, cyclooxygenase inhibitors, desmopressin, antifibrinolytics, gonadotropin-releasing hormone agonists, androgens, combined oral contraceptives, and progestins. Progestins can be administered systemically or locally and may be given cyclically or continuously. Increased use of effective medical therapies has the potential to reduce the number of surgical procedures, such as endometrial ablation and hysterectomy.

Menorrhagia and abnormal bleeding before the menopause

Abnormal uterine bleeding before the menopause accounts for 20% of visits to the gynaecology clinic and almost 25% of gynaecological operations. The patient who presents with such bleeding presents two distinct but important challenges for the clinician. The first is the exclusion of cancer or hyperplasia; the second is dealing with the annoyance as well as the fear that the bleeding engenders in the patient. Any attempt at appropriate therapy--whether surgical, hormonal or expectant--begins with an accurate diagnosis. Transvaginal ultrasound with saline infusion sonohysterography for selective patients has emerged as a safe, non-invasive and, inexpensive method of triaging patients with abnormal uterine bleeding in order to determine which patients require no further evaluation, blind endometrial sampling for a global endometrial process or visually directed endometrial sampling when pathology is thought to be focal.

Tranexamic acid: a review of its use in the management of menorrhagia

Tranexamic acid (Transamin), Cyklokapron, Exacyl, Cyklo-f) is a synthetic lysine derivative that exerts its antifibrinolytic effect by reversibly blocking lysine binding sites on plasminogen and thus preventing fibrin degradation. In a number of small clinical studies in women with idiopathic menorrhagia, tranexamic acid 2-4.5 g/day for 4-7 days reduced menstrual blood loss by 34-59% over 2-3 cycles, significantly more so than placebo, mefenamic acid, flurbiprofen, etamsylate and oral luteal phase norethisterone at clinically relevant dosages. Intrauterine administration of levonorgestrel 20 microg/day, however, produced the greatest reduction (96% after 12 months) in blood loss; 44% of patients treated with levonorgestrel developed amenorrhoea. Tranexamic acid 1.5 g three times daily for 5 days also significantly reduced menstrual blood loss in women with intrauterine contraceptive device-associated menorrhagia compared with diclofenac sodium (150 mg in three divided doses on day 1 followed by 25 mg three times daily on days 2-5) or placebo. Tranexamic acid, mefenamic acid, etamsylate, flurbiprofen or diclofenac sodium had no effect on the duration of menses in the studies that reported such data. In a large noncomparative, nonblind, quality-of-life study, 81% of women were satisfied with tranexamic acid 3-6 g/day for 3-4 days/cycle for three cycles, and 94% judged their menstrual blood loss to be 'decreased' or 'strongly decreased' compared with untreated menstruations. The most commonly reported drug-related adverse events are gastrointestinal in nature. The total incidence of nausea, vomiting, diarrhoea and dyspepsia in a double-blind study was 12% in patients who received tranexamic acid 1g four times daily for 4 days for two cycles (not significantly different to the incidence in placebo recipients). In conclusion, the oral antifibrinolytic drug tranexamic acid is an effective and well tolerated treatment for idiopathic menorrhagia. In clinical trials, tranexamic acid was more effective at reducing menstrual blood loss than mefenamic acid, flurbiprofen, etamsylate and oral luteal phase norethisterone. Although it was not as effective as intrauterine administration of levonorgestrel, the high incidence of amenorrhoea and adverse events such as intermenstrual bleeding resulting from such treatment may be unacceptable to some patients. Comparative studies of tranexamic acid with epsilon - aminocaproic acid, danazol and combined oral contraceptives, as well as long-term tolerability studies, would help to further define the place of the drug in the treatment of menorrhagia. Nevertheless, tranexamic acid may be considered as a first-line treatment for the initial management of idiopathic menorrhagia, especially for patients in whom hormonal treatment is either not recommended or not wanted.

Pathophysiology of endometrial bleeding

OBJECTIVES

To review the morphological and molecular events responsible for uterine bleeding in health and disease.

METHODS

Review of pertinent literature focusing on the histology and pathophysiology of normal and abnormal uterine bleeding (AUB).

RESULTS

The seat of normal menstrual bleeding is located in the upper two-thirds of the endometrial mucosa and is recognized by tissue necrosis, disruption of microvasculature, migratory leukocytes and platelet/fibrin thrombi in microvessels. The molecular events responsible for tissue and vascular breakdown are related to the release of proteolytic lysosomal enzymes of endometrial cell and inflammatory cell origin. In cases of AUB, tissue breakdown is located in the superficial layer (subsurface) of the endometrium. It is either focal (breakthrough bleeding) or diffuse (withdrawal bleeding). It is initiated by either chronic endometritis and/or microerosions or vascular fragility due to structural abnormalities of microvessels. Endometritis and microerosions occur in otherwise normal endometrium, polyps, submucosal leiomyomata, atrophy and cancer (organic causes). Primary vascular alterations are found in hyperestrogenic-type endometria, i.e. anovulatory dysfunctional uterine bleeding (DUB) and progestational-type endometrium, i.e. progestational contraceptives and combined, continuous hormonal replacement therapy (HRT) (non-organic causes). Ovulatory DUB and coagulation disorders are not appreciated histologically. These are related to impaired vasoconstriction and fibrinolysis and impaired coagulation factors, respectively.

CONCLUSIONS

Histology may contribute to better understanding of the mechanisms of action that initiate, regulate and lead to AUB. Better insight may trigger in the development of therapeutic procedures that could either prevent or control vascular breakdown which results in unexpected uterine bleeding.