Can we achieve international agreement on terminologies and definitions used to describe abnormalities of menstrual bleeding?

Myomectomy in adult women of reproductive age: a propensity score-matched study for pregnancy rates

PURPOSE

To study whether it is better to perform or not a myomectomy, in terms of surgical and reproductive outcomes in patients of advanced reproductive age, by an observational prospective study in university-affiliated and Community Hospitals.

MATERIALS AND METHODS

40 years and older patients affected by non-submucous symptomatic uterine fibroids and desiring future fertility were enrolled and treated by laparoscopic intracapsular myomectomy by (LIM) or by open laparotomy (OIM), or by a non-surgical management as control group, while attempting to conceive. The primary outcome measures were fibroid characteristics, pre- and post-surgical parameters, pregnancy achievement; the secondary outcome measures were the spontaneous or ART pregnancy outcomes, eventual week of abortion and type of delivery. Propensity scores have been calculated with logistic regression for binary and continuous variables.

RESULTS

202 patients completed the study: 112 operated by LIM, 40 by OIM and 50 patients as control group. Patients undergoing OIM have a worse surgical outcome than LIM. No difference was seen in pregnancy either after myomectomy or control group during follow-up. In the LIM group, there were 44 pregnancies (39.2%), and in the OIM group, there were 9 (22.5%) and 16 in the control group (32%). The weeks of delivery were statistically greater for the control group versus the surgical groups, with no difference in Apgar score between the 3 groups.

CONCLUSION

Patients aged over 40 years did not show substantial differences in reproductive outcome, whether operated or not. Myomectomy in over 40-year-old patients has no detrimental effect on future pregnancy rates and over when compared to expectant management.

Evaluation of Abnormal Uterine Bleeding in Adolescents: Single Center Experience

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.

A spatially resolved single-cell genomic atlas of the adult human breast

The adult human breast is comprised of an intricate network of epithelial ducts and lobules that are embedded in connective and adipose tissue1-3. Although most previous studies have focused on the breast epithelial system4-6, many of the non-epithelial cell types remain understudied. Here we constructed the comprehensive Human Breast Cell Atlas (HBCA) at single-cell and spatial resolution. Our single-cell transcriptomics study profiled 714,331 cells from 126 women, and 117,346 nuclei from 20 women, identifying 12 major cell types and 58 biological cell states. These data reveal abundant perivascular, endothelial and immune cell populations, and highly diverse luminal epithelial cell states. Spatial mapping using four different technologies revealed an unexpectedly rich ecosystem of tissue-resident immune cells, as well as distinct molecular differences between ductal and lobular regions. Collectively, these data provide a reference of the adult normal breast tissue for studying mammary biology and diseases such as breast cancer.

Our path from abnormal uterine bleeding and iron deficiency to impaired fetal development: A long and winding road

Abnormal 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.

Effectiveness of Persian Golnar on Excessive Menstrual Bleeding in Women with Abnormal Uterine Bleeding, Compared to Tranexamic Acid: A Triple-Blind, Randomized Equivalence Trial

Introduction

Abnormal uterine bleeding (AUB) is a major healthcare problem in females of reproductive age and impacts women's health and quality of life (QoL). This study aimed to test the equivalence of Persian Golnar (PG) and tranexamic acid (TA) for the treatment of excessive menstrual bleeding.

Method

A triple-blind randomized equivalence trial with parallel design and block randomization technique was performed. A total of 80 patients with AUB were randomly allocated to receive either PG or TA for three consecutive menstrual cycles. Blood loss was measured by the Pictorial Blood Loss Assessment Chart (PBAC). Hematological evaluations were done before the intervention and after treatment. QoL and premenstrual dysphoric disorder (PMDD) as secondary outcomes were assessed using the menorrhagia questionnaire (MQ) and Premenstrual Symptoms Screening Tool (PSST). Statistical analysis was performed using an independent t-test, paired t-test, χ2 test, Mann-Whitney test, and Wilcoxon signed-rank test.

Results

Seventy-six women completed the 12-week follow-up. Both PG and TA groups experienced a significant reduction in blood loss. Furthermore, the serum level of hemoglobin in the PG group enhanced significantly (P < 0.001). QoL and PMDD scores were significantly improved in both groups (P< 0.001).

Conclusion

The findings of the current trial supposed that the Golnar product is as effective as tranexamic acid in controlling bleeding and enhancing the quality of life and premenstrual symptoms.

Abnormal Uterine Bleeding during Pubertal Induction with Transdermal Estrogen in Turner Syndrome Individuals

STUDY OBJECTIVES

Incidence of abnormal uterine bleeding (AUB) during pubertal induction among individuals with Turner syndrome (TS) has not been described previously. We estimated the incidence and characterize factors associated with AUB among TS individuals. A secondary objective was to evaluate the management of AUB among this patient population.

DESIGN, SETTING, PARTICIPANTS, AND INTERVENTION

We conducted a retrospective chart review to evaluate TS individuals undergoing hormone replacement therapy (HRT) for pubertal induction with transdermal estrogen (TDE). A total of 45 participants were identified between January 2007 and June 2019.

RESULTS

Of the 45 TS individuals included, 16 (35%) experienced AUB. Individuals with AUB most commonly experienced prolonged (44%), prolonged and heavy (25%), and intermenstrual (19%) bleeding. Individuals who experienced AUB were more likely to experience spontaneous bleeding (69% vs. 28%) and a duration of unopposed estrogen greater than 18 months (63% vs. 41%), undergo progestin cycling less often than monthly (69% vs. 0%), use a micronized progestin dose of less than 200 mg (25% vs. 14%), and be noncompliant with HRT (19% vs. 0%) compared to those who did not experience AUB.

CONCLUSIONS

There is a relatively high incidence of AUB among TS individuals undergoing pubertal induction with TDE. Care providers should consider the clinical factors examined to guide monitoring and management of TS individuals on HRT.

Reporting of uterine fibroids on ultrasound examinations: an illustrated report template focused on surgical planning

Uterine fibroids are the most common benign gynecologic tumors in women of reproductive age, and ultrasound is the first-line imaging modality for their diagnosis and characterization. The International Federation of Gynecology and Obstetrics developed a system for describing and classifying uterine fibroids uniformly and consistently. An accurate description of fibroids in the ultrasound report is essential for planning surgical treatment and preventing complications. In this article, we review the ultrasound findings of fibroids, detailing the main points to be reported for preoperative evaluation. In addition, we propose a structured, illustrated report template to describe fibroids, based on the critical points for surgical planning.

Myofascial Pain Syndrome in Women with Primary Dysmenorrhea: A Case-Control Study

There is limited information on myofascial trigger points (MTrPs) and specific symptoms of chronic pelvic pain and, more specifically, dysmenorrhea. The objective of this study was to determine whether patients suffering from primary dysmenorrhea present alterations in mechanosensitivity and pain patterns, and greater presence of MTrPs in the abdominal and pelvic floor muscles. A case-control study was carried out with a total sample of 84 participants distributed based on primary dysmenorrhea and contraceptive treatment. The sample was divided into four groups each comprising 21 women. Data on pain, quality of life, and productivity and work absenteeism were collected; three assessments were made in different phases of the menstrual cycle, to report data on pressure pain threshold, MTrP presence, and referred pain areas. One-way ANOVA tests showed statistically significant differences (p < 0.01) between the groups, for the Physical Health domain and the total score of the SF-12 questionnaire, and for all the domains of the McGill questionnaire; but no significant differences were found in the data from the WPAI-GH questionnaire. Statistically significant data (p < 0.01) were found for mechanosensitivity in the abdominal area and limbs, but not for the lumbar assessment, within the group, with very few significant intergroup differences. The frequency of active MTrPs is higher in the groups of women with primary dysmenorrhea and during the menstrual phase, with the prevalence of myofascial trigger points of the iliococcygeus muscle being especially high in all examination groups (>50%) and higher than 70% in women with primary dysmenorrhea, in the menstrual phase, and the internal obturator muscle (100%) in the menstrual phase. Referred pain areas of the pelvic floor muscles increase in women with primary dysmenorrhea.

Motor Control and Regularity of Menstrual Cycle in Ankle and Knee Injuries of Female Basketball Players: A Cohort Study

Inadequate motor control facilitates ankle and knee injuries in female basketball. Although biomechanical analysis could help to detect it, aspects such as irregular menstruation make these associations controversial. We aimed to evaluate associations between 2D biomechanics during landing and proprioception with ankle and knee injuries of female basketball players, considering their menstruation regularity. Seventy-one players participated in this study. In the preseason, participants performed a drop-jump to obtain biomechanics during landing and a weight-bearing proprioception test. During the competitive season, all the non-contact ankle and knee injuries were registered. Data showed that 16% of players sustained an ankle or knee injury, being more frequent in players with irregular menstruation compared to regulars (22% vs. 13%, χ² = 6.009, p = 0.050, d = 0.6). Players who sustained a left-side injury displayed higher left-side dynamic valgus during landing than uninjured players (χ² = 25.88, p = 0.006, d = 1.5). The rest of the variables did not show any significant difference (p > 0.05). Monitoring 2D dynamic valgus from a drop-jump could help to detect inadequate motor control that may facilitate ankle or knee injuries of female basketball players, mainly for those with irregular menstruation. Proprioception seems not to be related to injuries.

Pre-clinical models to study abnormal uterine bleeding (AUB)

Abnormal Uterine Bleeding (AUB) is a common debilitating condition that significantly reduces quality of life of women across the reproductive age span. AUB creates significant morbidity, medical, social, and economic problems for women, their families, workplace, and health services. Despite the profoundly negative effects of AUB on public health, advancement in understanding the pathophysiology of AUB and the discovery of novel effective therapies is slow due to lack of reliable pre-clinical models. This review discusses currently available laboratory-based pre-clinical scientific models and how they are used to study AUB. Human and animal in vitro, ex vivo, and in vivo models will be described along with advantages and limitations of each method.

The FIGO Ovulatory Disorders Classification System

Ovulatory disorders are common causes of amenorrhea, abnormal uterine bleeding, and infertility, and are frequent manifestations of polycystic ovary syndrome (PCOS). There are many potential causes and contributors to ovulatory dysfunction that challenge clinicians, trainees, educators, and those who perform basic, translational, clinical, and epidemiological research. Similarly, therapeutic approaches to ovulatory dysfunction potentially involve a spectrum of lifestyle, psychological, medical, and procedural interventions. Collaborative research, effective education, and consistent clinical care remain challenged by the absence of a consensus comprehensive system for classification of these disorders. The existing and complex system, attributed to WHO, was developed more than three decades ago and did not consider more than 30 years of research into these disorders in addition to technical advances in imaging and endocrinology. This manuscript describes the development of a new classification of ovulatory disorders performed under the aegis of the International Federation of Gynecology and Obstetrics (FIGO) and conducted using a rigorously applied Delphi process. The stakeholder organizations and individuals who participated in this process comprised specialty journals, experts at large, national, specialty obstetrical and gynecological societies, and informed lay representatives. After two face-to-face meetings and five Delphi rounds, the result is a three-level multi-tiered system. The system is applied after a preliminary assessment identifies the presence of an ovulatory disorder. The primary level of the system is based on an anatomic model (Hypothalamus, Pituitary, Ovary) that is completed with a separate category for PCOS. This core component of the system is easily remembered using the acronym HyPO-P. Each anatomic category is stratified in the second layer of the system to provide granularity for investigators, clinicians, and trainees using the "GAIN-FIT-PIE" mnemonic (Genetic, Autoimmune, Iatrogenic, Neoplasm; Functional, Infectious and Inflammatory, Trauma and vascular; Physiological, Idiopathic, Endocrine). The tertiary level allows for specific diagnostic entities. It is anticipated that, if widely adopted, this system will facilitate education, clinical care, and the design and interpretation of research in a fashion that better informs progress in this field. Integral to the deployment of this system is a periodic process of reevaluation and appropriate revision, reflecting an improved understanding of this collection of disorders.

Clinical Usefulness of Non-Invasive Metabolic-Associated Fatty Liver Disease Risk Assessment Methods in Patients with Full-Blown Polycystic Ovary Syndrome in Relation to the MRI Examination with the Ideal IQ Sequence

The coexistence of polycystic ovary syndrome (PCOS) and liver steatosis has been studied for years. The gold standards for the diagnosis of liver steatosis are liver biopsy and magnetic resonance imaging (MRI), which are invasive and expensive methods. The main aim of this study is to check the usefulness of lipid accumulation product (LAP) and free androgen index (FAI) in the diagnosis of liver steatosis. The Ideal IQ MRI was performed in 49 women with PCOS phenotype A to assess the degree of liver steatosis, which was expressed with the proton density fat fraction (PDFF). Anthropometric examination and laboratory tests were performed, and the LAP and FAI were calculated. The correlation between MRI results and LAP, FAI, and one of the FAI components, sex hormone binding globulin (SHBG), was checked using statistical tests. There is a statistically significant correlation between PDFF and LAP and also between PDFF and FAI. LAP = 70.25 and FAI = 5.05 were established as cut-offs to diagnose liver steatosis. The SHBG is not a statistically significant parameter to predict liver steatosis. The study showed that especially LAP, but also FAI, can be used to predict liver steatosis with high specificity and sensitivity.

Identification of the LH surge by measuring intact and total immunoreactivity in urine for prediction of ovulation time

OBJECTIVES

In our earlier study, we separated three different molecular forms of urinary LH-ir (U-LH-ir) by gel filtration and identified them by immunoassay in urine from regularly menstruating women on periovulatory days. U-LH-ir is composed of intact luteinizing hormone (LH), its free beta-subunit (LHβ), and the core fragment of LHβ (LHβcf), the latter two establishing the non-intact portion of LH-ir. The aim was to determine whether timing of ovulation can be improved by detecting different molecular forms of U-LH-ir in women of reproductive age.

METHODS

We determined intact and total U-LH-ir in 14 regularly menstruating women on consecutive periovulatory days during the menstrual cycle. Non-intact LH-ir was calculated as the arithmetic difference between total and intact LH-ir. In addition, LH-ir was determined in both serum and urine from four of the women throughout the menstrual cycle.

RESULTS

During the LH surge, U-LH-ir consisted mainly of intact LH and presented with an abrupt increase. Intact U-LH-ir dropped rapidly within 1 day after the surge, reaching baseline levels at the end of the luteal phase. In contrast, LHβcf in urine increased further 1 day after the surge. After this, most of the U-LH-ir consisted of LHβcf and it remained strongly elevated (over fivefold compared to intact LH) for the first 3 days after the LH surge, moderately elevated (over threefold) thereafter until day + 5, and mildly elevated until day + 7.

CONCLUSIONS

Total and non-intact LH-ir are potential add-on characteristics which can be utilized in ovulation predictor kits to measure LH-ir in urine beyond the LH surge during a broader time frame, thereby paving the way for more precise prediction of the timing of ovulation than that obtained with currently available products.

The FIGO Ovulatory Disorders Classification System†

Ovulatory disorders are common causes of amenorrhea, abnormal uterine bleeding and infertility and are frequent manifestations of polycystic ovary syndrome (PCOS). There are many potential causes and contributors to ovulatory dysfunction that challenge clinicians, trainees, educators, and those who perform basic, translational, clinical and epidemiological research. Similarly, therapeutic approaches to ovulatory dysfunction potentially involve a spectrum of lifestyle, psychological, medical and procedural interventions. Collaborative research, effective education and consistent clinical care remain challenged by the absence of a consensus comprehensive system for classification of these disorders. The existing and complex system, attributed to the World Health Organization (WHO), was developed more than three decades ago and did not consider more than 30 years of research into these disorders in addition to technical advances in imaging and endocrinology. This article describes the development of a new classification of ovulatory disorders performed under the aegis of the International Federation of Gynecology and Obstetrics (FIGO) and conducted using a rigorously applied Delphi process. The stakeholder organizations and individuals who participated in this process comprised specialty journals, experts at large, national, specialty obstetrical and gynecological societies, and informed lay representatives. After two face-to-face meetings and five Delphi rounds, the result is a three-level multi-tiered system. The system is applied after a preliminary assessment identifies the presence of an ovulatory disorder. The primary level of the system is based on an anatomic model (Hypothalamus, Pituitary, Ovary) that is completed with a separate category for PCOS. This core component of the system is easily remembered using the acronym HyPO-P. Each anatomic category is stratified in the second layer of the system to provide granularity for investigators, clinicians and trainees using the 'GAIN-FIT-PIE' mnemonic (Genetic, Autoimmune, Iatrogenic, Neoplasm; Functional, Infectious and Inflammatory, Trauma and Vascular; Physiological, Idiopathic, Endocrine). The tertiary level allows for specific diagnostic entities. It is anticipated that, if widely adopted, this system will facilitate education, clinical care and the design and interpretation of research in a fashion that better informs progress in this field. Integral to the deployment of this system is a periodic process of reevaluation and appropriate revision, reflecting an improved understanding of this collection of disorders.

The FIGO ovulatory disorders classification system

Ovulatory disorders are common causes of amenorrhea, abnormal uterine bleeding, and infertility, and are frequent manifestations of polycystic ovary syndrome (PCOS). There are many potential causes and contributors to ovulatory dysfunction that challenge clinicians, trainees, educators, and those who perform basic, translational, clinical, and epidemiological research. Similarly, therapeutic approaches to ovulatory dysfunction potentially involve a spectrum of lifestyle, psychological, medical, and procedural interventions. Collaborative research, effective education, and consistent clinical care remain challenged by the absence of a consensus comprehensive system for classification of these disorders. The existing and complex system, attributed to WHO, was developed more than three decades ago and did not consider more than 30 years of research into these disorders in addition to technical advances in imaging and endocrinology. This manuscript describes the development of a new classification of ovulatory disorders performed under the aegis of the International Federation of Gynecology and Obstetrics (FIGO) and conducted using a rigorously applied Delphi process. The stakeholder organizations and individuals who participated in this process comprised specialty journals, experts at large, national, specialty obstetrical and gynecological societies, and informed lay representatives. After two face-to-face meetings and five Delphi rounds, the result is a three-level multi-tiered system. The system is applied after a preliminary assessment identifies the presence of an ovulatory disorder. The primary level of the system is based on an anatomic model (Hypothalamus, Pituitary, Ovary) that is completed with a separate category for PCOS. This core component of the system is easily remembered using the acronym HyPO-P. Each anatomic category is stratified in the second layer of the system to provide granularity for investigators, clinicians, and trainees using the "GAIN-FIT-PIE" mnemonic (Genetic, Autoimmune, Iatrogenic, Neoplasm; Functional, Infectious and Inflammatory, Trauma and Vascular; Physiological, Idiopathic, Endocrine). The tertiary level allows for specific diagnostic entities. It is anticipated that, if widely adopted, this system will facilitate education, clinical care, and the design and interpretation of research in a fashion that better informs progress in this field. Integral to the deployment of this system is a periodic process of reevaluation and appropriate revision, reflecting an improved understanding of this collection of disorders.

Criteria for Diagnosis of Polycystic Ovary Syndrome during Adolescence: Literature Review

Polycystic ovary syndrome (PCOS) is one of the most common endocrine conditions in women. PCOS may be more challenging to diagnose during adolescence due to an overlap with the physiological events of puberty, which are part of the diagnostic criteria in adult women. This review focuses on the evidence available in relation to PCOS diagnostic criteria for adolescents. Adolescent PCOS should be diagnosed using two main criteria irregular -menstrual cycles (relative to number of years post-menarche) and hyperandrogenism (clinical and/or biochemical); after excluding other conditions that mimic PCOS. Accurate definitions of the two main criteria will decrease challenges/controversies with the diagnosis and provide timely diagnosis during adolescence to establish early management. Despite the attempts to create accurate diagnostic criteria and definitions, this review highlights the limited research in this area, especially in the follow up of adolescents presenting with one diagnostic feature that are called “at risk of PCOS”. Studies in adolescents continue to use the Rotterdam diagnostic criteria that uses pelvic ultrasound. This is inappropriate, because previous and emerging data that show many healthy adolescents have polycystic ovarian morphology in the early years post-menarche. In the future, anti-Müllerian hormone levels might help support PCOS diagnosis if adolescents meet two main criteria.

Quality of life in Thai women with various types of abnormal uterine bleeding

OBJECTIVE

To determine the quality of life (QoL) in Thai women with various types of abnormal uterine bleeding (AUB).

METHODS

A cross-sectional study was conducted on 353 AUB patients between November 2010 and January 2012. They were grouped according to the duration of symptom: <6 months (acute AUB, n = 122), ≥6 months (chronic AUB, n = 138), and postmenopausal bleeding (PMB, n = 93); and the bleeding pattern: hypermenorrhea (n = 24) and irregular bleeding (n = 236). QoL was determined using the 36-Item Short-Form Health Survey (SF-36) Thai version.

RESULTS

The acute AUB and chronic AUB groups had a mean age of 43.84 ± 4.87 and 43.81 ± 6.55 years; they were younger than the PMB group (55.62 ± 7.55 years) (P < 0.001). Medical diseases were more prevalent in the PMB than in the acute and chronic groups (66.7% vs. 27.9% and 35.5%, respectively, P < 0.001). Some subscales of the SF-36 were significantly lower in the women with AUB than in those with normative values, in those with chronic AUB or PMB than in those with acute AUB, and in those with hypermenorrhea rather than in those with irregular bleeding.

CONCLUSION

Thai women with any AUB types have a poorer QoL than general Thai women. QoL tends to be poorer in women with symptoms longer than 6 months or with hypermenorrhea.

Histopathological pattern of endometrial biopsies in patients with abnormal uterine bleeding in a tertiary referral hospital in Jordan

BACKGROUND

Abnormal uterine bleeding (AUB) is a symptom that deviates from the normal menstrual cycle. AUB is characterized by changes in the frequency, volume, and duration of the menstrual flow. The etiology of AUB, which varies with age, may be attributed to both structural and non-structural causes.

OBJECTIVES

Determine the histopathological pattern of endometrial biopsies in patients with AUB across different age and parity groups who have undergone dilation and curettage (D&C), along with the discrepancy between D&C and histopathological findings after hysterectomy.

DESIGN

Retrospective chart review SETTING: Tertiary referral hospital PATIENTS AND METHODS: We collected data on all patients diagnosed with AUB between January 2015 and December 2020. Histopathological findings of all D&C endometrial biopsy samples were examined after being categorized by age and parity groups. Sensitivity, specificity, positive predictive value, and NPV were calculated to evaluate the diagnostic accuracy of D&C.

MAIN OUTCOME MEASURES

Histopathological pattern of D&C endometrial biopsies by age and parity groups.

SAMPLE SIZE

3233 patients.

RESULTS

Most patients were in the 18-39 year age group, with normal cyclical findings being the most common histopathological finding. Malignant lesions were observed in 42 patients with a majority being older than 50 years. In 13.3% (42/316) of patients, D&C failed to detect intrauterine disorder that was found on hysterectomy. The overall accuracy of D&C in determining the existence of normal versus pathological findings was 75.60%, the sensitivity was 72.90%, the specificity was 77.90%, the positive predictive value was 73.86% and the NPV was 77.05% in our patients.

CONCLUSION

Normal cyclic changes account for the highest proportion of histopathological findings. However, hyperplasia and malignancies are important causes of perimenopausal and postmenopausal bleeding. While the use of D&C as a sampling tool for AUB cases remains questionable, the use of D&C in diagnosing premalignant and malignant cases is highly effective.

LIMITATIONS

Single-center, retrospective design, incomplete medical records, and inter-rater reliability could not be determined.

CONFLICT OF INTEREST

None.

Historical Perspectives and Evolution of Menstrual Terminology

Abnormal uterine bleeding (AUB) in the reproductive years in non-pregnant women comprises a group of symptoms that include abnormal frequency and the irregular onset of flow as well as prolonged and heavy menstrual bleeding. It is a common, chronic, and debilitating condition affecting women worldwide with an adverse impact on their quality of life. Until the last decade, the “menstrual” terminology used to describe both normal and abnormal uterine bleeding and its underlying causes was inconsistent, creating considerable confusion. Using standardized terminology may potentially improve clinical management as well as help designing and interpreting basic, translational, epidemiological, and clinical research in women with menstrual problems. In this article, we explore the history and evolution of menstrual terminology and discuss the two International Federation of Gynecology and Obstetrics (FIGO) systems on i.e., (A) menstrual terminology and definitions (B) and the causes of AUB, achieved through international consensus of relevant stakeholders through a long multistage journey.

Menstrual cycle length and modern living: a review

PURPOSE OF REVIEW

The aim of this review is to evaluate biological, life history, environmental, and lifestyle factors and exposures that cause variability in menstrual cycle length (MCL).

RECENT FINDINGS

Recent literature has detailed a number of factors that influence MCL, with particular emphasis placed on novel environmental exposures, such as air pollution and endocrine disrupting chemicals.

SUMMARY

MCL varies widely in response to intrinsic and extrinsic inputs and is a useful predictor of reproductive health and fecundability.

VIDEO ABSTRACT

http://links.lww.com/COE/A28.

Detecting variations in ovulation and menstruation during the COVID-19 pandemic, using real-world mobile app data

BACKGROUND

As war and famine are population level stressors that have been historically linked to menstrual cycle abnormalities, we hypothesized that the COVID-19 pandemic could similarly affect ovulation and menstruation among women.

METHODOLOGY

We conducted a retrospective cohort study examining changes in ovulation and menstruation among women using the Natural Cycles mobile tracking app. We compared de-identified cycle data from March-September 2019 (pre-pandemic) versus March-September 2020 (during pandemic) to determine differences in the proportion of users experiencing anovulation, abnormal cycle length, and prolonged menses, as well as population level changes in these parameters, while controlling for user-reported stress during the pandemic.

FINDINGS

We analyzed data from 214,426 cycles from 18,076 app users, primarily from Great Britain (29.3%) and the United States (22.6%). The average user was 33 years of age; most held at least a university degree (79.9%). Nearly half (45.4%) reported more pandemic-related stress. Changes in average cycle and menstruation lengths were not clinically significant, remaining at 29 and 4 days, respectively. Approximately 7.7% and 19.5% of users recorded more anovulatory cycles and abnormal cycle lengths during the pandemic, respectively. Contrary to expectation, 9.6% and 19.6% recorded fewer anovulatory cycles and abnormal cycle lengths, respectively. Women self-reporting more (32.0%) and markedly more (13.6%) stress during the pandemic were not more likely to experience cycle abnormalities.

CONCLUSIONS

The COVD-19 pandemic did not induce population-level changes to ovulation and menstruation among women using a mobile app to track menstrual cycles and predict ovulation. While some women experienced abnormalities during the pandemic, this proportion was smaller than that observed prior to the pandemic. As most app users in this study were well-educated women over the age of 30 years, and from high-income countries, their experience of the COVID-19 pandemic might differ in ways that limit the generalizability of these findings.

The impact of COVID-19-related mental health issues on menstrual cycle characteristics of female healthcare providers

Aim

To investigate the association between menstrual cycle regularity in healthcare providers and COVID‐19 pandemic‐related anxiety, depression, stress.

Methods

A cross‐sectional study was conducted by administrating online questionnaires to female healthcare workers in Turkey. Women aged 18–40 years with regular menstrual cycles for more than 1 year before the beginning of the pandemic were included in the study and they were divided into two groups according to menstrual cycle regularity during the pandemic. The questionnaires included sociodemographic characteristics, medical and reproductive history, lifestyle information of participants, COVID‐19 Stress Scales (CSS), and a short version of the Depression Anxiety Stress Scale (DASS‐21).

Results

A total of 952 women were included in the study, 679 had regular menstrual cycles, and 273 had irregular menstrual cycles. The prevalence of irregular menses among Turkish women healthcare workers aged 18–40 years was 28.7%. The CSS subdimensions and total scores were significantly higher in the irregular menstruation group than in women with regular menstruation (p < 0.001). The DASS‐21 depression, anxiety, and stress subdimensions were likewise significantly higher in women with irregular menstruation (p < 0.001). Besides, both the univariable and the multivariable logistic regression results showed the relationship between irregular menstruation and CSS total score.

Conclusion

The current study showed the association between the COVID‐19 pandemic‐induced anxiety, perceived stress, depressive symptoms, and increased prevalence of menstrual cycle irregularity among healthcare providers.

Morphology and Biochemistry of Ovulation

The process of ovulation involves multiple and iterrelated genetic, biochemical, and morphological events: cessation of the proliferation of granulosa cells, resumption of oocyte meiosis, expansion of cumulus cell-oocyte complexes, digestion of the follicle wall, and extrusion of the metaphase-II oocyte. The present narrative review examines these interrelated steps in detail. The combined or isolated roles of the follicle-stimulating hormone (FSH) and luteinizing hormone (LH) are highlighted. Genes indiced by the FSH genes are relevant in the cumulus expansion, and LH-induced genes are critical for the resumption of meiosis and digestion of the follicle wall. A non-human model for follicle-wall digestion and oocyte release was provided.

Menstrual related discomfort and associated factors among undergraduate students in Ambo University, Central Ethiopia

Background:

Menstruation is a natural phenomenon which is an indicator of women’s health that occurs throughout the reproductive years of every female. This phenomenon is unique to the females and governed by the girl’s general health condition, genetic, socioeconomic, and nutritional factors. Although it is a normal physiological process, most females experience some degree of pain and discomfort in their menstruation period. Even though there are limited studies so far reported about the issue in some other parts of the country, there is no scientific evidence in the present study area.

Objective:

To assess menstrual-associated discomfort and associated factors among undergraduate students in Ambo University, Central Ethiopia, 2018.

Methods:

Institution-based cross-sectional study was conducted at Ambo University from 30 March to 30 April 2018. Stratified sampling technique was used and 748 study participants were randomly selected from faculties using a multi-stage sampling procedure. Only data from 713 study participants were entered into EpiData 3.1 and analyzed using SPSS version 20.0 software. Logistic regression was used to associate factors with menstrual-associated discomfort. All statistical tests were considered as significant at a p-value of < 0.05.

Result:

The prevalence of menstrual-associated discomfort was found to be 68.6%. The variables age (Being younger) (adjusted odds ratio = 3.9 (95% confidence interval: 1.28, 11.78)), Tigire ethnicity (adjusted odds ratio = 2.4 (95% confidence interval: 1.02, 5.75)), unmarried (adjusted odds ratio = 2.1 (95% confidence interval: 1.21, 3.76)), smokers (adjusted odds ratio = 2.2 (95% confidence interval: 1.12, 4.29)), drinking caffeine (adjusted odds ratio = 1.8 (95% confidence interval: 1.17, 2.74)), amount of flow (adjusted odds ratio = 2.4 (95% confidence interval: 1.28, 4.62)), and duration of pain (adjusted odds ratio = 4.2 (95% confidence interval: 1.93, 9.29)) were significantly associated with menstrual-associated discomfort.

Conclusion:

This study revealed that majority of the participants was experienced with menstrual-associated discomfort. As the tendency of smoking cigarettes, drinking caffeine, and amount of flow is increased, menstrual associated discomfort is increased. Therefore, specific plan of action and support is urgently needed in order to enlighten and treat menstrual-associated discomfort.

[Safety and acceptability of the 52 mg levonorgestrel-releasing intrauterine system in women with abnormal uterine bleeding in an ambulatory care center in Bogotá, Colombia, 2012-2016]

OBJECTIVE

To describe safety and acceptability with the use of the 52-mg levonorgestrel-releasing intrauterine system in women with abnormal uterine bleeding.

METHODS

Retrospective cohort of women 18 years of age and older diagnosed with abnormal uterine bleeding, ultrasound-reported uterine length between 6 and 10 cm and uniform endometrial cavity in its entire length, regardless of structural abnormality, who received treatment with 52-mg levonorgestrel-releasing intrauterine system between 2012 and 2016. Non-probabilistic convenience sampling was carried out. Sociodemographic and clinical baseline variables were measured, as well as patient perception of bleeding and the frequency of failure, amenorrhea, need for hysterectomy and adverse events, over a 12-month follow-up period. Descriptive statistics were applied.

RESULTS

Overall, 200 patients were assessed. A subjective perception of improvement in terms of bleeding volume and frequency of leave of absence or visits to the emergency department was found; 90 % of the patients had amenorrhea, and 6 % experienced adverse events.

CONCLUSIONS

The 52-mg levonorgestrel-releasing intrauterine system is a safe option for the management of abnormal uterine bleeding in women with normal uterine size and no submucosal endometrial abnormalities. Local randomized studies are required to assess effectiveness and efficiency in comparison with other management options.

Menstrual Patterns in the First Gynecological Year: A Systematic Review

STUDY OBJECTIVE

Understanding what constitutes a normal menstrual cycle during the first gynecological year (GY1) is a common concern of adolescents and clinicians. However, limited high-quality evidence exists. We aimed to summarize published literature regarding menstrual and ovulatory patterns in GY1. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Electronic databases (MEDLINE, Pre-MEDLINE, Embase, Web of Science, CINAHL, Cochrane Library) were systematically searched from database inception to 2018. Eligible studies described menstrual cycles, symptoms, or validated ovulatory data in healthy adolescents in GY1. Two authors independently screened studies, extracted data, and assessed methodological quality.

RESULTS

Twenty-two studies involving more than 2000 adolescents were included. Thirteen recorded menstrual cycle and/or symptom data and 14 measured ovulation. Mean cycle length ranged from 32 to 61 days and decreased throughout GY1. Mean menses length was 4.9 to 5.4 days. Frequent menstrual bleeding was reported in up to 23% of participants, infrequent menstrual bleeding in up to one-third, and "irregular menstrual bleeding" in up to 43%. Dysmenorrhea was reported by 30%-89% of participants. Prevalence of ovulatory cycles identified using luteal phase serum or salivary progesterone or urinary pregnanediol was 0 to 45% and increased throughout GY1. However, all used definitions that would be considered subovulatory in clinical practice.

CONCLUSION

Menstrual and ovulatory patterns in GY1 are diverse and differ from those of adults. A transitional phase of menstrual and ovulatory immaturity is common. However, ovulation, irregular cycles, and dysmenorrhea are not uncommon. As such, safe sexual practice should be advocated and prompt medical management should be accessible.

The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions

BACKGROUND

The International Federation of Gynecology and Obstetrics (FIGO) systems for nomenclature of symptoms of normal and abnormal uterine bleeding (AUB) in the reproductive years (FIGO AUB System 1) and for classification of causes of AUB (FIGO AUB System 2; PALM-COEIN) were first published together in 2011. The purpose was to harmonize the definitions of normal and abnormal bleeding symptoms and to classify and subclassify underlying potential causes of AUB in the reproductive years to facilitate research, education, and clinical care. The systems were designed to be flexible and to be periodically reviewed and modified as appropriate.

OBJECTIVES

To review, clarify, and, where appropriate, revise the previously published systems.

METHODOLOGY AND OUTCOME

To a large extent, the process has been an iterative one involving the FIGO Menstrual Disorders Committee, as well as a number of invited contributions from epidemiologists, gynecologists, and other experts in the field from around the world between 2012 and 2017. Face-to-face meetings have been held in Rome, Vancouver, and Singapore, and have been augmented by a number of teleconferences and other communications designed to evaluate various aspects of the systems. Where substantial change was considered, anonymous voting, in some instances using a modified RAND Delphi technique, was utilized.

Treatment patterns and healthcare resource utilization and costs in heavy menstrual bleeding: a Japanese claims database analysis

AIMS

Heavy menstrual bleeding (HMB) is a highly prevalent condition, characterized by excessive menstrual blood loss and cramping, that interferes with activities of daily life. The aim of this study was to investigate treatment patterns in HMB in Japan, and to assess healthcare resource utilization and costs among women newly-diagnosed with the condition.

MATERIALS AND METHODS

This study retrospectively analyzed health insurance data available in the Japan Medical Data Center (JMDC) database on women aged 18-49 years who were newly-diagnosed with primary or secondary HMB. Treatment patterns were analyzed, and healthcare utilization and costs were evaluated and compared to matched controls.

RESULTS

The study included a total of 635 patients, 210 with primary HMB and 425 with secondary HMB. In the primary HMB cohort, 60.0% of patients received one or more pharmacological or surgical treatments, compared with 76.2% in the secondary HMB cohort. The most commonly prescribed medications in all patients were hemostatic agents (28.7%), traditional Chinese medicine (TCM) (12.1%), and low-dose estrogen progestins (LEPs) (10.1%). After adjustment for patient baseline characteristics, healthcare costs were 1.93-times higher in primary HMB cases (p < .0001) and 4.44-times higher in secondary HMB cases (p < .0001) vs healthy controls. Outpatient care was the main cost driver.

LIMITATIONS

The main limitations of this study are related to its retrospective nature, and the fact that only reimbursed medications were captured in the source database.

CONCLUSIONS

A substantial proportion of HMB patients did not receive the recommended treatments. Healthcare costs were considerably increased in the presence of an HMB diagnosis.

Abnormal Uterine Bleeding in Adolescents

Abnormal uterine bleeding (AUB) is the most common gynecologic complaint of adolescents admitted to hospital. Heavy menstrual bleeding (HMB) is the most frequent clinical presentation of AUB. Anovulatory cycles, owing to immature hypothalamic-pituitary-ovarian axis, is the leading etiology of HMB and there is an accompanying bleeding disorder in almost 20% of patients with HMB. Additionally, endocrine disorders such as hypothyroidism, hyperprolactinemia and polycystic ovary syndrome are possible causes of AUB. Exclusion of bleeding disorders, especially of von Willebrand disease is important for diagnosis and treatment of HMB, particularly in cases with AUB, which has been present since menarche. Management of HMB is based on the underlying etiology and severity of the bleeding. After other causes are excluded, anovulatory heavy bleeding can be treated successfully with combined oral contraceptives and iron supplementation either as an outpatient or in hospital depending on the clinical findings and level of anemia. The epidemiology, clinical presentation, diagnostic approach and treatment of HMB is discussed and our clinical experience in this field is presented in this review.

Abnormal Uterine Bleeding: Current Classification and Clinical Management

Abnormal uterine bleeding is now classified and categorized according to the International Federation of Gynecology and Obstetrics classification system: PALM-COEIN. This applies to nongravid women during their reproductive years and allows more clear designation of causes, thus aiding clinical care and future research.

Critical evaluation of the PALM-COEIN classification system among women with abnormal uterine bleeding in low-resource settings

OBJECTIVE

To assess the feasibility of the PALM-COEIN system for the classification of abnormal uterine bleeding (AUB) in low-resource settings and to suggest modifications.

METHODS

A prospective study was conducted among women with AUB who were admitted to the gynecology ward of a tertiary care hospital and research center in central India between November 2014 and October 2016. All patients were managed as per department protocols. The causes of AUB were classified before treatment using the PALM-COEIN system (classification I) and on the basis of the histopathology reports of the hysterectomy specimens (classification II); the results were compared using classification II as the gold standard.

RESULTS

The study included 200 women with AUB; hysterectomy was performed in 174 women. Preoperative classification of AUB per the PALM-COEIN system was correct in 130 (65.0%) women. Adenomyosis (evaluated by transvaginal ultrasonography) and endometrial hyperplasia (evaluated by endometrial curettage) were underdiagnosed.

CONCLUSION

The PALM-COEIN classification system helps in deciding the best treatment modality for women with AUB on a case-by-case basis. The incorporation of suggested modifications will further strengthen its utility as a pretreatment classification system in low-resource settings.

Ovulation, a sign of health

The concept of the ovarian continuum can be understood as a process that occurs during a woman's lifetime and begins during intrauterine life with fertilization. Women start their reproductive years with approximately five hundred thousand follicles containing oocytes, of which only around five hundred will be released during ovulation. Ovulation has been recognized as an event linked with reproduction; however, recent evidence supports the role of ovulation as a sign of health. The use of biomarkers that help women recognize ovulation enables them to identify their health status. This knowledge helps medical healthcare providers in the prevention, diagnosis, and treatment of different pathologies related with endocrine disorders, gynecological abnormalities, autoimmune, genetic, and neoplastic diseases, as well as pregnancy-related issues. The knowledge of the ovarian continuum and the use of biomarkers to recognize ovulation should be considered a powerful tool for women and medical professionals.

Summary

The ovarian continuum is a process that occurs during a woman's lifetime. It begins during intrauterine life with fertilization and ends with menopause. This process can be greatly affected by different conditions such as changes in hormonal levels and illnesses. Therefore, understanding and promoting the knowledge and use of biomarkers of ovulation in women is a key aspect to consider when evaluating their health status. The knowledge and education about the ovarian continuum should be taken into account as a powerful tool for women and medical professionals.

How I treat heavy menstrual bleeding associated with anticoagulants

Anticoagulant-associated heavy menstrual bleeding (HMB) is an underrecognized but not uncommon problem in clinical practice. Premenopausal women should be advised of the potential effect of anticoagulant therapy on menstrual bleeding at the time of treatment initiation. Consequences of HMB should be assessed and treated on an ongoing basis. In the acute setting, the decision to withhold anticoagulants is based on an individual patient's risk of thrombosis and the severity of the bleeding. For women who require long-term anticoagulation, a levonorgestrel intrauterine system, tranexamic acid (during menstrual flow), high-dose progestin-only therapy, or combined hormonal contraceptives are effective for controlling HMB. The risk of thrombosis during anticoagulant therapy with these treatments is not well studied but is likely to be low. Selection of type of hormonal therapy is based on patient preference, other indications for and contraindications to therapy, adverse effect profile, and ongoing thrombotic risk factors. Women who do not respond to medical treatment or who do not wish to retain their fertility should be considered for surgical management.

Abnormal uterine bleeding

INTRODUCTION

It is not uncommon for a woman to suffer from abnormal uterine bleeding (AUB) or heavy menstrual bleeding (HMB) at some point during her lifetime. Once pathology is excluded, in practice, management needs to be individualised, taking into account the improvement of the woman's symptoms and quality of life.

SOURCES OF DATA

Peer-reviewed journals, governmental and professional society publications.

AREAS OF AGREEMENT

There is now agreement on a structured, universal approach to the diagnosis of AUB, with the aide memoirs PALM (polyps, adenomyosis, leiomyoma, malignancy) and COEIN (coagulopathies, ovulatory dysfunction, endometrial, iatrogenic, not otherwise classified). Once malignancy and significant pelvic pathology have been ruled out, medical treatment is an effective first-line therapeutic option, with surgery, including endometrial ablation and hysterectomy, offered when medical management has failed to resolve symptoms and fertility is no longer desired.

AREAS OF CONTROVERSY

There remains controversy around the management of the types and subtypes of adenomyosis and leiomyoma, and understanding their impact on clinical reproductive outcomes.

AREAS CURRENTLY UNDER DEVELOPMENT

Standardised assessment tools for measuring outcomes of AUB are being developed.

AREAS TIMELY FOR DEVELOPING RESEARCH

Novel diagnostic and monitoring tools should be developed to help stratify treatment for women with AUB, particularly relating to 'unclassified' and 'endometrial' causes.

Examining Menstrual Tracking to Inform the Design of Personal Informatics Tools

We consider why and how women track their menstrual cycles, examining their experiences to uncover design opportunities and extend the field's understanding of personal informatics tools. To understand menstrual cycle tracking practices, we collected and analyzed data from three sources: 2,000 reviews of popular menstrual tracking apps, a survey of 687 people, and follow-up interviews with 12 survey respondents. We find that women track their menstrual cycle for varied reasons that include remembering and predicting their period as well as informing conversations with healthcare providers. Participants described six methods of tracking their menstrual cycles, including use of technology, awareness of their premenstrual physiological states, and simply remembering. Although women find apps and calendars helpful, these methods are ineffective when predictions of future menstrual cycles are inaccurate. Designs can create feelings of exclusion for gender and sexual minorities. Existing apps also generally fail to consider life stages that women experience, including young adulthood, pregnancy, and menopause. Our findings encourage expanding the field's conceptions of personal informatics.

Comparison of classic terminology with the FIGO PALM-COEIN system for classification of the underlying causes of abnormal uterine bleeding

OBJECTIVE

To compare classic terminology and the PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory disorders, endometrium, iatrogenic, and not classified) classification system among women who underwent surgery for abnormal uterine bleeding (AUB), and to subclassify the components of the PALM group for future studies.

METHODS

In a retrospective study, data were obtained for nonpregnant women aged 18-55years who underwent hysterectomy, myomectomy, or polypectomy for AUB at a center in Turkey in 2014. The patients were retrospectively classified according to the PALM-COEIN system, and the two terminologies were compared.

RESULTS

A total of 471 women were included. The term "hypermenorrhea" covered 15 different pathology combinations, "menorrhagia" nine, "metrorrhagia" 14, and "menometrorrhagia" 18. Of 92 patients with polyp, 5 (5.4%) had two polyps and 1 (1.1%) had three. Of 146 patients with adenomyosis, 131 (89.7%) had diffuse adenomyosis and 12 (8.2%) had adenomyoma. Of 309 patients with myoma uteri, 108 (34.9%) had submucous myoma and 201 (65.1%) had other types of myoma.

CONCLUSION

Classic terminology for AUB is insufficient and confusing with respect to etiologic pathologies among nonpregnant women of reproductive age. Widespread adoption of the PALM-COEIN system for AUB classification will facilitate more meaningful communication among both clinicians and investigators, and clarify the populations that should be evaluated in clinical trials, thereby enhancing communication with patients.

Cost-Effectiveness of Global Endometrial Ablation vs. Hysterectomy for Treatment of Abnormal Uterine Bleeding: US Commercial and Medicaid Payer Perspectives

Cost-effectiveness modeling studies of global endometrial ablation (GEA) for treatment of abnormal uterine bleeding (AUB) from a US perspective are lacking. The objective of this study was to model the cost-effectiveness of GEA vs. hysterectomy for treatment of AUB in the United States from both commercial and Medicaid payer perspectives. The study team developed a 1-, 3-, and 5-year semi-Markov decision-analytic model to simulate 2 hypothetical patient cohorts of women with AUB-1 treated with GEA and the other with hysterectomy. Clinical and economic data (including treatment patterns, health care resource utilization, direct costs, and productivity costs) came from analyses of commercial and Medicaid claims databases. Analysis results show that cost savings with simultaneous reduction in treatment complications and fewer days lost from work are achieved with GEA versus hysterectomy over almost all time horizons and under both the commercial payer and Medicaid perspectives. Cost-effectiveness metrics also favor GEA over hysterectomy from both the commercial payer and Medicaid payer perspectives-evidence strongly supporting the clinical-economic value about GEA versus hysterectomy. Results will interest clinicians, health care payers, and self-insured employers striving for cost-effective AUB treatments.

Recent advances in managing and understanding menstrual disorders

Menstrual disorders are a major reason for gynaecological consultations worldwide and, unfortunately there are many different definitions and classifications of this condition. Clear definitions and terminology are necessary for scientific literature, particularly for clinicians, and for clinical trials comparing two treatments. The International Federation of Gynaecology and Obstetrics (FIGO) Menstrual Disorders Working Group has proposed abandoning the use of one common term, dysfunctional uterine bleeding (DUB), while continuing to use the terms abnormal uterine bleeding (AUB) and heavy menstrual bleeding (HMB). Furthermore, the group issued the PALM-COEIN classification system for menstrual disorders, which has quickly been adopted around the world. The PALM-COEIN system allows clinicians and researchers to identify and classify women with both AUB and HMB in a systematic manner, provides reliable information for research purposes and for epidemiological and prevalence studies in different settings, and supports accurate diagnoses and treatment. Additionally, this classification system is useful for selecting treatments appropriate for different stages of women's reproductive years and for different patterns of menstrual bleeding. Among the proposed treatments are the use of combined oral contraceptives, the levonorgestrel-releasing intrauterine system, tranexamic acid, mefenamic acid, and other nonsteroidal anti-inflammatory drugs (NSAIDs).