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Increasing cesarean section rates have led to an increased awareness of associated complications such as the formation of cesarean scar niche, defined as an indentation at the site of the cesarean scar with a depth of at least 2 mm, diagnosed by ultrasound or magnetic resonance imaging. The precise prevalence of cesarean scar niche is unclear. The cause of a cesarean scar niche appears to be multifactorial and likely a combination of technical factors (low incision location), anatomical factors (uterine retroflexion), and patient factors, which might impair healing (body mass index, smoking, maternal age). Most patients with cesarean scar niche are asymptomatic; however, women can present with postmenstrual bleeding, pelvic pain, and subfertility. In pregnancy, cesarean scar niches have been associated with placenta accreta spectrum disorder and uterine rupture. Treatment should be reserved for symptomatic women. Hormonal treatment using either the combined oral contraceptive pill or a progesterone-containing intrauterine device may address irregular vaginal bleeding. Surgical management should be reserved for those in whom hormonal manipulation has failed or is contraindicated. The aim of this review was to summarize current literature pertaining to the cause, prevalence, diagnosis, and symptoms of cesarean scar niche and to make recommendations for managing this relatively new condition., (© 2022 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

It has been suggested that impaired venous drainage and endometrial vascular ectasia (EMVE), secondary to increased intramural pressure, explains abnormal bleeding in fibroid uteri. Striking EMVE with extravasated red blood cells (ecchymosis) has also been seen in uteri with grossly obvious myometrial hyperplasia (MMH), suggesting that increased intramural pressure can cause EMVE in the absence of fibroids. EMVE with MMH may explain the century old association of clinically enlarged uteri with abnormal bleeding, and this same mechanism may be operative in myopathic uteri with grossly obvious adenomyosis. EMVE with associated thrombosis, ecchymosis, and/or stromal breakdown is commonly seen in random sections of hysterectomies for bleeding. EMVE may also be associated with endothelial hyperplasia, consistent with a reaction to endothelial injury due to impaired venous drainage. This further supports the theory that EMVE bleeds when thrombosis occurs, due to Virchow's Triad (stasis, endothelial injury, and hypercoagulability). EMVE may be "the lesion for which surgery was performed" in hysterectomies with otherwise unexplained bleeding., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Most endometrial cancer cases are preceded by abnormal uterine bleeding, offering a potential opportunity for early detection and cure of endometrial cancer. Although clinical guidelines exist for diagnostic workup of abnormal uterine bleeding, consensus is lacking regarding optimal management for women with abnormal bleeding to diagnose endometrial cancer., Objective: We report the baseline data from a prospective clinical cohort study of women referred for endometrial evaluation at the Mayo Clinic, designed to evaluate risk stratification in women at increased risk for endometrial cancer. Here, we introduce a risk-based approach to evaluate diagnostic tests and clinical management algorithms in a population of women with abnormal bleeding undergoing endometrial evaluation at the Mayo Clinic., Study Design: A total of 1163 women aged ≥45 years were enrolled from February 2013 to May 2019. We evaluated baseline absolute risks and 95% confidence intervals of endometrial cancer and endometrial intraepithelial neoplasia according to clinical algorithms for diagnostic workup of women with postmenopausal bleeding (assessment of initial vs recurrent bleeding episode and endometrial thickness measured through transvaginal ultrasound). We also evaluated risks among women with postmenopausal bleeding according to baseline age (<60 vs 60+ years) as an alternative example. For this approach, biopsy would be conducted for all women aged 60+ years and those aged <60 years with an endometrial thickness of >4 mm. We assessed the clinical efficiency of each strategy by estimating the percentage of women who would be referred for endometrial biopsy, the percentage of cases detected and missed, and the ratio of biopsies per case detected., Results: Among the 593 women with postmenopausal bleeding, 18 (3.0%) had endometrial intraepithelial neoplasia, and 47 (7.9%) had endometrial cancer, and among the 570 premenopausal women with abnormal bleeding, 8 (1.4%) had endometrial intraepithelial neoplasia, and 7 (1.2%) had endometrial cancer. Maximum risk was noted in women aged 60+ years (17.7%; 13.0%-22.3%), followed by those with recurrent bleeding (14.7%; 11.0%-18.3%). Among women with an initial bleeding episode for whom transvaginal ultrasound was recommended, endometrial thickness did not provide meaningful risk stratification: risks of endometrial cancer and endometrial intraepithelial neoplasia were nearly identical in women with an endometrial thickness of >4 mm (5.8%; 1.3%-10.3%) and ≤4 mm (3.6%; 0.9%-8.6%). In contrast, among those aged <60 years with an endometrial thickness of >4 mm, the risk of endometrial cancer and endometrial intraepithelial neoplasia was 8.4% (4.3%-12.5%), and in those with an endometrial thickness of ≤4 mm, the risk was 0% (0.0%-3.0%; P=.01). The most efficient strategy was to perform biopsy in all women aged 60+ years and among those aged <60 years with an endometrial thickness of >4 mm, with the lowest percentage referred to biopsy while still detecting all cases., Conclusion: Existing clinical recommendations for endometrial cancer detection in women with abnormal bleeding are not consistent with the underlying risk. Endometrial cancer risk factors such as age can provide important risk stratification compared with the assessment of recurrent bleeding. Future research will include a formal assessment of clinical and epidemiologic risk prediction models in our study population as well as validation of our findings in other populations., (Published by Elsevier Inc.)

Anogenital mammary-like glands, formerly described as ectopic breast tissue, are currently considered to be normal histologic components of the anogenital region. Anogenital mammary-like glands can give rise to many lesions identical to counterparts in the native female breast. We describe four cases of such lesions, including fibroadenoma, gynecomastia-like hyperplasia, and ectopic mammary-type tissue with a spectrum of usual ductal hyperplasia, apocrine metaplasia, adenosis, and pseudolactational change. All four cases occurred in young women (ages 29-38) who presented with vulvar or perianal masses. Similar to previously reported cases, these lesions shared histologic and immunohistochemical characteristics identical to native female breast lesions. Novel findings in our cases included (1) the first case of gynecomastia-like change to be reported in the perianal area of a female, (2) Immunohistochemical staining identifying a 3-layered epithelium characterized by a population of CK14 and CK5/6 positive and hormone receptor negative superficial luminal cells, and (3) diffuse, strong positivity for GATA3 in all cases. Our study adds to the literature on these rare lesions and highlights findings which may be useful in understanding the pathogenesis and improving the diagnosis of anogenital mammary-like gland lesions., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Study Objective: Cesarean scar defect (CSD) is often associated with postmenstrual bleeding, infertility, and pain. Hysteroscopic CSD repair was described in the past, mainly as excision of the proximal edge of the defect to allow continuous blood flow during menstruation. In this study we aimed to evaluate the efficacy of extensive hysteroscopic cesarean scar niche excision in symptomatic patients., Design: A retrospective cohort study., Patients: Symptomatic patients treated with hysteroscopic CSD excision who were considered eligible for the procedure when myometrial thickness of 2 mm or more was observed on sonohysterography., Setting: Tertiary referral center., Interventions: Extensive CSD excision was performed using a cutting loop and pure cutting current. The proximal and distal edges of the defect were resected. This was followed by resection of tissue at the base of the niche, until underling muscular tissue was evident. Tissue sampled from the base of the CSD was collected for histologic examination. Patients were followed for a minimum of 1 year after hysteroscopic CSD excision. Clinical information obtained included detailed obstetric history and preoperative and postoperative menstruation pattern., Measurements and Main Results: Between 2011 and 2016, 95 patients underwent extensive hysteroscopic niche excision; 67 were included in the study, whereas the remaining were lost to follow-up. Patient mean age at the time of the procedure was 38 ± 5.5 years. Twenty-nine patients (43%) had a history of high-order repeat cesarean surgeries. Sixty-six patients (98.5%) presented with postmenstrual bleeding, 26 with secondary infertility (38.8%), and 2 with pelvic pain (2.9%). After hysteroscopic niche excision, 63.4% of patients reported significant improvement or resolution of postmenstrual bleeding. A statistically significant reduction in number of bleeding days per cycle (15.5 ± 4.8 vs 9.8 ± 4.7, p < .001) was also noted. Histologic evidence for myometrial tissue within the obtained samples was associated with better outcomes. A histologic specimen from patients who experienced significant improvement or resolution of postmenstrual bleeding was more likely to reveal myometrial tissue (p = .04). Of the 26 patients who suffered from infertility, 19 attempted to conceive spontaneously after CSD excision. Of those, 10 patients (52.6%) conceived and 9 delivered at least once (47.36%)., Conclusion: Extensive hysteroscopic surgical excision of cesarean scar niche should be considered in symptomatic patients suffering from irregular menstrual bleeding. The quality of the excision at the apex of the niche could be associated with a higher success rate. The role of niche excision to overcome secondary infertility should be further evaluated., (Copyright © 2019. Published by Elsevier Inc.)

Abnormal uterine bleeding (AUB) is an extremely common problem and represents a clinical area of unmet need. It has clinical implications and a high cost for the healthcare system. The PALM-COEIN acronym proposed by FIGO may be used as a foundation of care; it improves the understanding of the causes of AUB, and in doing so facilitates effective history taking, examination, investigations, and management. Heavy menstrual bleeding, a subset of AUB, is a subjective diagnosis and should be managed in the context of improving the woman's quality of life. Available evidence suggests that there is poor satisfaction with standard treatment options often resulting in women opting for major surgery such as hysterectomy. Such women would benefit from a tailored approach, both for diagnosis and treatment, highlighting the deficiency of biomarkers in this area. This article focuses on the causes of AUB as per the PALM-COEIN acronym, the researched biomarkers in this area, and the potential pathogenetic mechanisms. In the future, these approaches may improve our understanding of AUB, thereby enabling us to direct women to most suitable current treatments and tailor investigative and treatment strategies to ensure best outcomes, in keeping with the principles of personalized or precision medicine., (© The Author(s) 2018. Published by Oxford University Press on behalf of Society for the Study of Reproduction.)

Introduction: Factor XI (FXI) deficiency is a mild bleeding disorder, common among Ashkenazis, that may be underestimated in Caucasians. Management of FXI deficiency in women is a challenge, due to its unpredictable bleeding tendency and the little evidence available on this issue., Objective: To describe gynaecological/obstetrical bleeding complications and to analyze the effectiveness and safety of the antihaemorrhagic treatment among women with FXI deficiency., Material and Methods: A retrospective, observational study of 214 Caucasian subjects with FXI deficiency collected during 20 years (1994-2014) without clinical selection., Results: We identified 95 women with FXI deficiency. Any haemorrhagic event was communicated by 26/95 (27.4%), being abnormal uterine bleeding the most frequently found (12/95, 12.6%). Nine postpartum haemorrhages were recorded from 136 deliveries (6.6%) in 57 women. Four postsurgical bleeding complications were registered among 25 gynaecological surgeries (16%) in 20 women. Abnormal uterine bleeding, postpartum and postsurgical haemorrhages were related to both a positive bleeding history and FXI:C values ≤43.5%. Prophylaxis with fresh frozen plasma, used in 12/25 (48%) gynaecological surgeries, did not prevent from postoperative bleeding in three cases, but two developed severe adverse reactions., Conclusion: Women with FXI deficiency, especially those with a positive history of bleeding or FXI:C ≤43.5%, are at risk of developing gynaecological/obstetrical haemorrhages, most of them mild/moderate. Systematic prophylaxis has questionable effectiveness, but might cause severe side effects., (Copyright © 2019 Elsevier España, S.L.U. All rights reserved.)

A 34-year-old woman presented our hospital with complaint of irregular menstruation and abnormal uterine bleeding lasting for a month. After her second parturition at the age of 27, her menstrual cycle had been regular, but it suddenly became irregular at the age of 30. Transvaginal ultrasound revealed the presence of ovarian mass, and the patient underwent diagnostic laparoscopic surgery. Bilateral ovaries temporally shrink after puncture but the size soon resumed. Gonadotropins were almost normal, but estradiol and PRL levels turned out to be elevated, and cabergoline treatment was initiated. After referral to our hospital, we found that the ovaries showed multifollicular appearance. Brain magnetic resonance imaging showed an 18-mm macroadenoma in the suprasellar area. To suppress the secretion of endogenous gonadotropins and estrogen, low-dose estrogen-progestin was prescribed. Surprisingly, the treatment temporarily reduced the size of the ovaries. The patient was referred to a neurosurgeon, and a functioning gonadotroph adenoma was suspected. After the resection of the pituitary tumor, her menstrual cycle became regular, and the size of bilateral ovaries became normal. We also noticed that her ovarian reserve judged by anti-Müllerian hormone had been almost diminished after the surgical treatment, probably reflecting the exhaustion of follicular pool. Women with multifollicular ovaries and elevated estradiol levels may have functioning gonadotroph adenomas, although the level of FSH is relatively normal, and ovarian reserve can be followed by measuring anti-Müllerian hormone.

An isthmocele, a cesarean scar defect or uterine niche, is any indentation representing myometrial discontinuity or a triangular anechoic defect in the anterior uterine wall, with the base communicating to the uterine cavity, at the site of a previous cesarean section scar. It can be classified as a small or large defect, depending on the wall thickness of the myometrial deficiency. Although usually asymptomatic, its primary symptom is abnormal or postmenstrual bleeding, and chronic pelvic pain may also occur. Infertility, placenta accrete or praevia, scar dehiscence, uterine rupture, and cesarean scar ectopic pregnancy may also appear as complications of this condition. The risk factors of isthmocele proven to date include retroflexed uterus and multiple cesarean sections. Nevertheless, factors such as a lower position of cesarean section, incomplete closure of the hysterotomy, early adhesions of the uterine wall and a genetic predisposition may also contribute to the development of a niche. As there are no definitive criteria for diagnosing an isthmocele, several imaging methods can be used to assess the integrity of the uterine wall and thus diagnose an isthmocele. However, transvaginal ultrasound and saline infusion sonohysterography emerge as specific, sensitive and cost-effective methods to diagnose isthmocele. The treatment includes clinical or surgical management, depending on the size of the defect, the presence of symptoms, the presence of secondary infertility and plans of childbearing. Surgical management includes minimally invasive approaches with sparing techniques such as hysteroscopic, laparoscopic or transvaginal procedures according to the defect size.

Painful menstruation, premenstrual syndrome and metrorrhagia iuvenilis are one of the most common problems related to the sexual cycle in adolescent girls. Metrorrhagia iuvenilis is acyclic bleeding that occurs in adolescents and lasts from over 10 days even up to 3 months. These bleeds are very abundant and have a tendency to relapse. They cause anemia, and severe cases can be life-threatening. Premenstrual Syndrome (PMS) is a cluster of somatic, emotional and behavioural symptoms occurring in the luteal phase of the menstrual cycle. The aetiology of PMS remains unknown. According to strict diagnostic criteria, an estimated 2.5-5% of girls and women are affected by PMS. However, some researchers maintain that the symptoms of PMS may be prevalent in as many as 40-80% of girls and women. This article it has been discussed premenstrual syndrome and metrorrhagia iuvenilis and aspects related to dietotherapy were included.

We present first case report on itraconazole, a drug very commonly used for onychomycosis, used along with simvastatin that caused metrorrhagia. The suggested probable mechanism is the inhibition of steroidogenesis, especially estrogens that resulted in low-estrogen breakthrough bleeding. This article emphasizes the importance of drug interaction check prior the initiation of onychomycosis treatment., Competing Interests: There are no conflicts of interest.

Objectives: Aiming to evaluate the profile type, complaint and outcome of patients consulting a gynecologic emergency unit in order to enhance "real" emergencies and improve their management., Materials and Methods: We enrolled prospectively 308 women consulting to Reims teaching hospital gynecologic emergency unit from the 15th of May to the 25th of June 2013., Results: Two hundred and fifty-seven women (83.4%) spontaneously consulted without previous medical examination. Two hundred and thirty-eight of them (77.3%) had already been through gynecologic emergency units and 99 (32.1%) had no regular follow-up. Pelvic pain and/or metrorragia were registered as main complaint for 219 patients (71.1%). Median age was thirty years old (±11) and an average forty-minute wait was recorded. Gynecologic ultrasound was the first exam to be performed after clinical examination for 255 patients (82.8%). Twenty-two (7.1%) were hospitalized for surgical procedures or medical care, respectively 10 (3.2%) and 12 (3.9%). Among 51 women addressed by another healthcare professional, 9 were hospitalized (17.6%) versus 12 hospitalized (4.7%) out of 257, when consulting without initial professional expertise. A significant relationship between hospitalizations and general practitioner consultation was found with an OR=4.34 (95%CI: 1.51-12.05, P=0.002). Main motive of consultation involving home treatment turned out to be on-going pregnancies (92 patients, 29.9%)., Conclusion: A large majority of gynecologic hospital consultations, responsible for time waste and professional monopolizing, can be treated by general practitioners and could contribute to a better management of life-threatening emergencies., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Objective To observe the correlation between serum sex hormone levels and different syndrome types of Chinese medicine (CM) in dysfunctional uterine bleeding (DUB) patients. Methods Totally 532 DUB patients were classified into 10 different syndrome types according to syndrome typing theories of CM, including Gan-depression transforming heat syndrome, Shen deficiency blood sta- sis syndrome, Shen-yin deficiency syndrome, Pi-Shen deficiency syndrome, qi and yin deficiency syndrome, qi and blood deficiency syndrome, Pi deficiency syndrome, qi stagnation blood stasis syndrome, damp-heat syndrome, yin deficiency blood heat syndrome. Besides, 6 serum levels of sex hormone were measured including follicular stimulating hormone (FSH) , luteinizing hormone (LH) , estradiol (E₂) , progesterone (P) , testerone (T) , and prolactin (PRL) in patients with different syndrome types. Correlation study between syndrome types and sex hormones were performed using Logistic regression analysis. Results The distributions of DUB in CM were sequenced from high to low as uterine bleeding, menostaxis, preceded menstrual cycle, intermenstrual bleeding, and menorrhagia. The distributions of syndrome types were sequenced from high to low as yin deficiency blood heat syndrome, qi and blood deficiency syndrome, qi stagnation blood stasis syndrome, Shen-yin deficiency syndrome, Pi-Shen deficiency syndrome, Gan-depression transforming heat syndrome, Pi deficiency syndrome, Shen deficiency blood stasis syndrome, qi and yin deficiency syndrome, damp-heat syndrome. PRL level was positively correlated with Gan-depression transforming heat syndrome in the ratio of 1. 117 (P <0. 05). FSH level was positively correlated with Shen-yin deficiency syndrome in the ratio of 1. 327 (P <0. 05). LH level was positively correlated with Pi-Shen deficiency syndrome in the ratio of 1.342 (P <0.05). Conclusions DUB patients with various syndrome types of CM had different levels of sex hormones, with certain-laws manifested. Positive correlation existed between PRL level and Gan-depression transforming heat syn- drome, FSH level and Shen-yin deficiency syndrome, LH level and Pi-Shen deficiency syndrome.

Objective: To evaluate the impact of an episode of intermenstrual bleeding on the probability of conception in a menstrual cycle (fecundability)., Design: Prospective, time-to-pregnancy cohort study., Setting: Community-based cohort., Patient(s): Women trying to conceive, ages 30 to 44 years, without known infertility., Intervention(s): Not applicable., Main Outcome Measure(s): Current cycle and subsequent cycle fecundability., Result(s): A total of 549 women provided 1,552 complete cycles for analysis. Intermenstrual and luteal bleeding were reported in 36% and 34% of cycles, respectively. Ninety-three percent of all intermenstrual bleeding was luteal. Cycles in which women had intermenstrual bleeding or luteal bleeding were statistically significantly less likely to result in conception (fecundability ratio [FR] 0.23; 95% confidence interval [CI], 0.16-0.34; and FR 0.22; 95% CI, 0.14-0.33). Women with an episode of intermenstrual and luteal bleeding had a statistically significant increase in the probability of pregnancy in the subsequent cycle (FR 1.61; 95% CI, 1.15-2.25; and FR 2.01; 95% CI, 1.52-2.87, respectively)., Conclusion(s): Intermenstrual bleeding statistically significantly decreases the odds of conceiving in that cycle but does not appear to negatively impact a woman's immediate future reproductive potential., Clinical Trial Registration Number: NCT01028365., (Copyright © 2016 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Adolescent females frequently present to the ED with complaints that may be caused by a gynecologic emergency. Differentiating and excluding some of the common and most serious gynecologic emergencies reviewed in this article are critical. Timely and effective treatment of these conditions, once diagnosed, can result in better health outcomes.

Objective: To evaluate practice patterns of gynecologists in the management of abnormal uterine bleeding (AUB) in South Korea., Methods: Between February 24 and March 12, 2014, a cross-sectional survey was performed through face-to-face interviews with 100 gynecologists selected through quota sampling reflecting regions and hospital types. Through the use of a questionnaire, the level of awareness and practice patterns regarding diagnosis and management of AUB were evaluated., Results: Among 100 respondents, 60 reported that they had not previously heard of the International Federation of Gynecology and Obstetrics (FIGO) classification system. The standardization of AUB terminology was reported to be necessary or very necessary by 70 respondents. Pelvic ultrasonography would be used for diagnosis by 99 physicians. The most common first-line AUB treatment was combined oral contraceptives: 55 respondents would use them for heavy menstrual bleeding, 56 for intermenstrual bleeding, and 56 for polycystic ovary syndrome. Combined oral contraceptives were the preferred follow-up medication: 30 would use them for heavy menstrual bleeding, 24 for intermenstrual bleeding, and 52 for polycystic ovary syndrome., Conclusion: Despite implementation of the FIGO AUB classification system and guidelines, awareness and use among gynecologists in South Korea remains low., (Copyright © 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.)

Objective: To understand the meaning of endometrial thickening and bleeding in postmenopausal women who had previously undergone endometrial ablation (EA)., Design: Retrospective observational study. Canadian Task Force III., Setting: Obstetrics and Gynecology Unit, Magna Graecia University, Catanzaro, Italy., Patients: Sixty-three postmenopausal women who had previously undergone EA., Interventions: A retrospective evaluation of clinical charts of postmenopausal women who had a follow-up visit after EA between January 2000 and August 2014., Measurements and Main Results: The rates of endometrial thickening (with or without bleeding), endometrial atrophy, and cancer were determined. Postmenopausal bleeding was reported in 9 patients (14.3%). Endometrial thickening was observed in 51 patients (80.9%; mean ± SD endometrial thickness, 7.7 ± 3.0 mm). A significantly (p < .05) greater number of patients with an endometrial thickness of 5 to 10 mm was observed compared with those with an endometrial thickness of <5 mm or >10 mm. A significant (p = .001) difference in increase in endometrial thickness was observed between patients with and without bleeding. Overall, hysteroscopy plus endometrial biopsy was scheduled in 24 patients. In all bleeding women, a histological diagnosis of endometrial atrophy was demonstrated. Concerning bleeding-free women, in 14 patients with endometrial thickening of >10 mm, mucosal atrophy was detected. The only bleeding-free patient in whom an endometrial echogenic fluid collection was detected had a histological diagnosis of endometrioid endometrial cancer. Thus, patients who underwent hysteroscopy had a 95.8% rate of mucosal atrophy and a 4.2% rate of endometrial cancer. The overall cancer rate in our global population (menopause with previous EA) was 1.6%., Conclusion: Postmenopausal bleeding and sonographic detection of endometrial thickening in patients with previous EA are not necessarily related to a malignant disease. Nonetheless, ultrasound visualization of endometrial thickening plus an echogenic endometrial fluid collection in these patients always warrants an invasive diagnostic procedure regardless of whether or not bleeding is reported., (Copyright © 2015 AAGL. Published by Elsevier Inc. All rights reserved.)

The study compared ultrasound and ambulatorial hysteroscopy as diagnostic methods detecting endometrial polyps in postmenopause women. 281 women aged 41-82 years who underwent ambulatorial hysteroscopy were analyzed for presence of uterine bleeding and/or altered transvaginal ultrasound (endometrial thickness ≥5 mm). Ultrasonography detected endometrial polyps in 22.8% of patients and endometrial thickening in the other 59.8%. Hysteroscopy diagnosed endometrial polyps in 80.8%. Ultrasonography showed sensitivity of 88.7%, specificity of 25.4%, positive predictive value of 81.7%, negative predictive value of 37.5% and accuracy of 75.4% in diagnosing endometrial polyps. Hysteroscopy showed 96.4% sensitivity, 74.6% specificity, 93.4% positive predictive value, 84.6% negative predictive value and 91.8% accuracy. Hysteroscopy demonstrated more accuracy than ultrasonography, which is not sufficient for accurate diagnosis.

The aim of this study was to investigate the relation between Celiac disease (CD) and unexplained dysfunctional uterine bleeding (DUB) in celiac women. The celiac patients were selected from women who were referred to celiac department. Controls were selected from those women without any signs of celiac disease and matched with age. Meanwhile, a trained physician was ready to explain the study, and then in case of their allowance, a questionnaire was completed by the physician. 24 % of celiac women reported a past history of at least one menstrual cycle disorder vs 10 % of controls reported these problems (p=0.038) and higher percentage of unexplained DUB has been observed in celiac women. All celiac patients were undertaking gluten free diet for at least 3 months and the celiac patients who reported the history of DUB were again interviewed for any signs of unexplained DUB. From 12 celiac women with DUB, 10 patients reported no more unexplained DUB after getting gluten-free diet (83.3 %). The occurrence of a significant correlation between CD and DUB suggests the possibility of considering CD as one of the potential causes of abnormal uterine bleeding. Therefore, celiac disease must be seriously considered in the screening of patients with reproductive disorders (Tab. 2,Ref. 23).

Heavy menstrual bleeding (HMB) is a common clinical problem; population-based studies estimate that approximately 10-35% of women report this symptom during their lifetime, while about 5% of women consult a physician for evaluation of HMB. Patients with HMB account for 15% of all referrals to gynaecologists and are frequently seen by haematologists in bleeding disorder clinics as well. Heavy menstrual bleeding can be caused by a wide variety of local and systemic factors, so a careful clinical and laboratory evaluation is often necessary to determine the aetiology and guide appropriate management. This review discusses the definition, causes and clinical outcomes of HMB. It outlines a diagnostic approach and focuses on medical (as opposed to surgical) treatments. Throughout, areas of controversy and opportunities for further research are highlighted., (© 2013 John Wiley & Sons Ltd.)

Background/aim: Abnormal uterine bleeding is the most common problem which brings woman to the gynecologist during the postmenopausal period. The aim of this study was to define the significance of hysteroscopy as a diagnostic procedure for the evaluation of patients with postmenopausal bleeding, as well as to define it as a surgical procedure by which the cause of bleeding can be treated in most cases in the same sitting., Methods: The study involved 148 female patients referred to the Clinic for Gynecology and Obstetrics in Nis for postmenopausal bleeding in the period of 12 months. Hysteroscopy with endometrial biopsy were performed in all the patients. Biopsy materials were directed to histological examination, and the hysteroscopic and histological findings were compared afterwards. Polyps and submucous miomas were hysteroscopically removed in the same sitting and also directed to histological examination., Results: The success rate of the method was 95.1%, while complications occurred in 1.37% of the cases. The hysteroscopic findings were normal in almost 30% of the cases, and the most common pathological finding was endometrial polyp. The sensitivity of hysteroscopy in the detection of intrauterine pathology was 100%, the specificity 81%, the positive predictive value 92% and the negative predictive value 100%. In 69.7% of the patients the cause of bleeding was hysteroscopically removed. Hysteroscopy was performed in 58.1% of the patients in the same sitting, and in 11.6% of the patients after obtaining histological findings., Conclusion: Hysteroscopy is a safe, highly sensitive diagnostic procedure, thus being an ideal method for evaluation of patients with postmenopausal bleeding. The application of hysteroscopy with endometrial biopsy leads to accurate diagnosis. An adequate diagnosis is crucial for the selection of relevant treatment of postmenopausal bleeding and avoidance of unnecessary major surgical procedures. Except for being a diagnostic method hysteroscopy, is also an outpatient minimally invasive surgical procedure for treating the cause of bleeding in the majority of cases in the same sitting.

Abnormal uterine bleeding (AUB), which is defined as excessively heavy, prolonged and/or frequent bleeding of uterine origin, is a frequent cause of visits to the Emergency Department and/or health care provider. While there are many etiologies of AUB, the one most likely among otherwise healthy adolescents is dysfunctional uterine bleeding (DUB), which is characterizing any AUB when all possible underlying pathologic causes have been previously excluded. The most common cause of DUB in adolescence is anovulation, which is very frequent in the first 2-3 post-menarchal years and is associated with immaturity of the hypothalamic - pituitary - ovarian axis. Management of AUB is based on the underlying etiology and the severity of the bleeding and primary goals are prevention of complications, such as anemia and reestablishment of regular cyclical bleeding, while the management of DUB can in part be directed by the amount of flow, the degree of associated anemia, as well as patient and family comfort with different treatment modalities. Treatment options for DUB are: combined oral contraceptives (COCs), progestogens, non steroidal anti inflammatory drugs (NSAIDs), tranexamic acid (anti-fibrinolytic), GnRH analogues, Danazol and Levonorgestrel releasing intra uterine system (LNG IUS).

Many women aged 40-55 years suffer from abnormal uterine bleeding or heavy menstrual bleeding. Not all general practitioners and specialists, however, are aware of the developments in diagnostic and therapeutic possibilities for abnormal uterine bleeding. We present 3 patients with heavy menstrual bleeding who were treated at our one-stop clinic. In one patient, a 45-year-old woman, a small fibroid was removed with a Twizzle bipolar electrode. The second patient, a 47-year-old woman, opted for an endometrial ablation which was performed directly under local anaesthesia. The third patient, a 42-year-old woman, had an endometrial polyp removed with a duckbill snare. The clinic for diagnosis and therapy in one consult has advantages for the patient. Today, technological advances in instruments and equipment have made it possible to treat many types of intracavitary abnormalities directly in the ambulatory setting, for example, the resection of small fibroids or intrauterine polyps and use of the second-generation endometrial ablation technique.

Abnormal uterine bleeding is one of the most common presenting complaints encountered in a gynecologist's office or primary care setting. The availability of diagnostic tools, such as ultrasound, endometrial sampling, and diagnostic hysteroscopy has made it possible to promptly diagnose and treat an increasing number of menstrual disorders in an office setting. The incorporation of newer medical therapies: antifibrinolytic drugs, shorter hormone-free interval oral contraceptive pills, and levonorgestrel inserts along with office minimally invasive treatments operative hysteroscopy and endometrial ablations have proven to be powerful therapeutic arsenals to provide short-term relief of abnormal uterine bleeding, and potentially, avoiding or delaying the hysterectomy.

Objectives: To develop a conceptually and semantically valid Arabic version of a validated disease-specific instrument of quality of life (QoL) for women with abnormal uterine bleeding (AUB)., Methods: This is a prospective cohort study conducted at the Department of Obstetrics & Gynecology, King Saud University, Riyadh, Kingdom of Saudi Arabia between December 2010 and December 2011 following ethics approval. Forward translation of the Aberdeen Menorrhagia Severity Scale (AMSS) from English into Arabic was followed by backward translation of the consensus target (Arabic) version into the source (English) language. Subsequently, a final target (Arabic) language version was created. Sixty-one Arabic-speaking women of reproductive age participated in the study. The final Arabic questionnaire was administered to 41 women with self-perceived normal menses (Group 1) on 2 occasions 2 weeks apart. Agreement in the answers deems the questionnaire reliable. The final Arabic version was administered to 20 women with self-perceived AUB (Group 2), and their scores were compared with the first response of Group 1. A significant difference between the groups deems the questionnaire valid., Results: For linguistic validation; intra-class correlation coefficient (ICC) of 0.87 and Kappa statistics of 0.56 to 0.87 indicated good to excellent agreement. For clinical validation, there was a significant difference between Group 1 and 2 (p=0.001)., Conclusion: The translated Arabic AMSS is a reliable and valid indicator of QoL in Saudi women with AUB.

Abnormal uterine bleeding is one of the most common reasons that reproductive-aged women seek health care. The causes are varied, depending in large part on the age and life stage of the woman. Thus, diagnosis requires a systematic approach that is driven by a thorough health history and review of presenting symptoms. In recent years, the treatment of abnormal uterine bleeding has moved away from surgical procedures in favor of more conservative, yet effective, hormonal therapy such as combined contraceptives and the levonorgestrel-releasing intrauterine system. Clinicians must be knowledgeable about the various abnormal uterine bleeding treatment options and partner with women to develop appropriate, individualized treatment plans. The purpose of this article is to synthesize the current literature to describe the contributing etiologies, common presentations, diagnosis, evaluation, and management of abnormal uterine bleeding., (© 2012 by the American College of Nurse-Midwives.)

Background: A retained intrauterine device is a rare, but easily correctable, cause of postmenopausal bleeding (PMB)., Case: A 64-year-old woman presented to her gynecologist with PMB. Sonographic evaluation of the endometrium revealed the presence of a Cu-7 IUD retained for at least 30 years. Hysteroscopically assisted retrieval of the IUD resulted in complete resolution of symptoms., Conclusion: A retained IUD should be considered in the differential diagnosis for PMB. In addition, the authors recommend pelvic sonography as the first-line diagnostic modality for PMB to aid the diagnosis of retained IUD as well as other pathology.

Background: A significant number of women are referred with bleeding problems related to the use of hormonal contraception, for advice on management of heavy periods or following difficulty with intrauterine device insertion. The authors describe their experience with Instillagel(®) as the contrast medium for hysterosonography in a one-stop clinic for complex contraception referrals. They also comment on its analgesic properties for cervical and uterine instrumentation., Methods: The authors reviewed 275 referrals seen over a 6-month period in consultant-delivered clinics provided by a contraception service that serves a single county (population 500 000). They describe the simple technique they use for hysterosonography with Instillagel., Results: The authors found Instillagel useful as a contrast medium for sonographic assessment of the endometrial cavity. Additionally, presence of gel in the endometrial cavity, with a time interval between insertion of gel and uterine instrumentation, appears to result in analgesia and relaxation of the uterus. There was a very low incidence of difficulties in a group of patients who had previously experienced significant problems with uterine instrumentation., Conclusions: Hysterosonography is an efficacious, simple and inexpensive technique for assessment of the endometrial cavity. It has many potential applications in contraceptive care. An additional benefit appeared to be that once gel was instilled in the cavity for 10-15 minutes it facilitated instrumentation of the uterus.

A 45 years old woman having dysfunctional uterine bleeding was scheduled for total abdominal hysterectomy with bilateral salpingo-oophorectomy under general anaesthesia. On pre-operative anaesthesia assessment, she was found to have junctional rhythm at rate of 44 beats/minute with bigeminies and pre-mature ventricular contractions on ECG. On further evaluation, she was diagnosed as having congenital sinus node dysfunction on the basis of 24 hours Holter monitoring. She was asymptomatic, no prior comorbidity and belonged to functional class one. General anaesthesia was successfully managed by vigilance, invasive monitoring, standby transcutaneous and transvenous pacemakers; use of cardiostable and vagolytic anaesthetic agents like Etomidate, Atracurium and Pethidine during the procedure and for postoperative pain management. Transcutaneous external pacing pads were placed just after induction of anaesthesia, their functional apability was confirmed and was ready for use if needed. The transcutaneous and transvenous pacemakers were on backup and both were not required. Patient was successfully managed and was discharged home on third postoperative day with uneventful hospital course. The elective pacemaker implantation was therefore not required.

Menometrorrhagia, defined as excessive and prolonged uterine bleeding occurring at irregular and/or frequent intervals, occurs in up to 24% of women aged 40-50 years. There are a wide range of causes of menometrorrhagia, although histological differences in endometrium between women aged <45 years compared with those aged 48-50 years indicate a much higher prevalence of myomas, adenomyosis, and dysfunctional endometrium (dysfunctional uterine bleeding, hyperplasia, neoplasia) around the time of the premenopause, emphasizing the importance of accurate diagnosis and appropriate management in women of this age group. In women presenting with menometrorrhagia, it is imperative to recognize that underlying lesions and diagnosis are frequently missed due to multiple causes. Primary diagnosis needs to exclude pregnancy and cancer, whereas secondary investigations (including ultrasound with instillation of saline solution, hysteroscopy and biopsy, and magnetic resonance imaging) can assist in accurately diagnosing the underlying cause of menometrorrhagia.

Objective: The objective of this study was to evaluate the effectiveness of BLADE (proprietary name for periodically rotated overlapping parallel lines with enhanced reconstruction [PROPELLER] in MR systems from Siemens Healthcare) MRI compared with conventional T2-weighted fast spin-echo (FSE) MRI for reducing artifacts and improving image quality when imaging the female pelvis., Materials and Methods: Sagittal T2-weighted BLADE and FSE examinations of the pelvis of 26 women were performed on a 1.5-T scanner. Three radiologists assessed the images for the presence of artifacts, level of anatomic detail, and overall image quality using a modified Likert scale. Scores for each radiologist and each imaging sequence were analyzed with a linear mixed model, adjusting for correlation within radiologist and within patient. A quantitative comparison was conducted to investigate signal uniformity., Results: The BLADE sequence was superior for evaluation of the junctional zone (p = 0.0019), delineation of ovarian borders and depiction of follicles (p < 0.0001), and detection of fibroids (p = 0.022). Overall image quality was improved with BLADE, with fewer respiratory motion artifacts. The BLADE sequence introduced "radial" artifact that was absent from the FSE images, but this artifact did not affect image quality. Quantitative analysis revealed mean coefficients of variation for BLADE and FSE in the uterus of 21.6% and 22.5%, respectively (p = 0.36). The mean coefficients of variation were 4.6% and 6.1% in fat (p = 0.0007), indicating less variation with BLADE. The mean acquisition times for the BLADE and FSE sequences were 4 minutes 31 seconds and 3 minutes 46 seconds, respectively., Conclusion: Imaging of uterine junctional zone anatomy, ovaries, and fibroids was improved and artifacts were reduced with BLADE compared with FSE. Radial artifact introduced by the BLADE sequence and slightly longer imaging times needed for the BLADE sequence were offset by improved image quality.

Abnormal uterine bleeding in women is a common cause for gynecologic consultation. Physicians must maintain a low threshold for endometrial assessment in abnormal uterine bleeding. Accurately determining the etiology of the bleeding permits appropriate treatment, minimizes unnecessary delays in therapy, and prevents needless worry in women. There are few national consensus guidelines, best practice guidelines, or treatment algorithms that provide gynecologists with scrupulous data to make concise decisions for the utilization of technology such as endometrial biopsy, transvaginal ultrasound, saline infusion sonography, or hysteroscopy in the evaluation of menstrual aberrations. Using technology that has a high sensitivity to detect a disease allows a physician to make concise decisions for proceeding with minimally invasive procedures or reliance on medical therapies that will probably be effective., (© 2011 by The North American Menopause Society)

Research is ongoing into the mechanisms of abnormal uterine bleeding, including bleeding from organic etiologies, where there is an intrinsic uterine lesion. Most of the current studies are focused on abnormalities of angiogenesis. By elucidating these mechanisms, targeted therapies can be developed. This article reviews the literature on pathologic mechanisms involved in bleeding from organic etiologies., (© 2011 by The North American Menopause Society)

A three-year-old, sexually intact, female American Staffordshire terrier was presented with chronic postpartum vulvar haemorrhage. Sixty-one days before presentation, the bitch had whelped 10 puppies. A tentative diagnosis of subinvolution of placental sites was made when syncythial trophoblast-like cells were identified in the specimen collected through the opening of the cervix by endoscopy. Five weeks after the diagnosis, the bitch was clinically healthy with no vaginal bleeding and spontaneous recovery occurred without surgical treatment., (© 2010 British Small Animal Veterinary Association.)

Irregular or unusually heavy periods are a common complaint. Most often, the condition is benign and can by managed conservatively. Assess postmenopausal women for cancer by endometrial biopsy, transvaginal ultrasound, or saline infusion sonohysterogram. Treat mild dysfunctional uterine bleeding (DUB) with nonsteroidal anti-inflammatory drugs, levonorgestrel intrauterine device (IUD), or danazol. Treat moderate DUB with oral contraceptive pills, levonorgestrel IUD, danazol, or tranexamic acid.

In patients with AIDS, infection with Histoplasma capsulatum frequently results in disseminated disease. We discuss a 42-year old HIV-infected woman presenting with fever, weight loss, pulmonary infiltrates, diarrhea, and metrorrhagia. Biopsy of bone marrow and skin demonstrated H capsulatum. Necrotic lesions of the uterine cervix, initially thought to represent cervical carcinoma, proved to be because of disseminated histoplasmosis. Involvement of the female genital tract by histoplasmosis is exceedingly rare, with cervical disease not having been described previously.

Background: The vaginal route is more effective than the other drug delivery routes for some specific indications., Aim: To compare the efficacy of a vaginal progesterone preparation with that of oral dydrogesterone., Methods: A total of 69 women with irregular dysfunctional uterine bleeding were randomly assigned into one of two groups: oral dydrogesterone group (n = 35) and vaginal progesterone group (n = 34). At the end of a three-month treatment period, the women were re-evaluated. The endometrial histology findings and menstrual cycle characteristics were used as primary outcome measures. Pearson chi-square and Fisher's exact test were used for data analysis., Results: Findings from 54 eligible women were evaluated. There was no statistically significant difference in both menstrual recordings and endometrial histology results between the groups., Conclusions: Vaginal micronised progesterone could be an alternative to oral preparations in the treatment of dysfunctional uterine bleeding. This needs to be further evaluated in adequately controlled randomised trials against other effective treatments.

A strategy to establish the diagnosis and the etiology of menorrhagia is necessary for an adaptated therapeutic care. The cross-examination must endeavour to assess bleedings and their clinical impact, and concentrate on specific pathology (such as hemostasis disorders). Clinical examination may eliminate cervical vaginal pathologies and estimate uterine volume. The diagnosis of pregnancy should always be considered and eliminated and that of iron deficiency anemia will be helpful. Explorations of hemostasis balance will be recommended according to clinical and biological features. Hormonal measurement are not contributive, except in diagnosis of SOPK. Endometrium biopsy with the Pipelle will be systematically performed after 40 years of age or in case of risk factors of endometrial cancer. Transvaginal ultrasonography is the first line exam to recommend in case of proved menorrhagia. Hysteroscopy and hysterosonography will be recommended if ultrasonography is not informative enough, or in case of medical treatment failure. MRI is recommended in an second intention (in case of multiple uterine fibroids, or suspected adenomyosis, and if an arterial embolization is required).

Office hysteroscopy may be performed without anaesthesia. Endometrial biopsy can be performed during hysteroscopy. Antalgics or other treatment to reduce discomfort are not indicated. Prophylactic antibiotics are not indicated. Diagnostic value of hysteroscopy for endometrial pathology is interesting. Pipelle is the most appropriate instrument for endometrial biopsy.

Menometrorrhagia is a frequent cause of medical consulting. After a clinical examination showing the uterine origin of bleeding and that excludes a cervical or vulvo-vaginal origin, transvaginal sonography (TVS) represents the first-line technique examination. TVS allows to identify endometrial diseases (atrophy, polyps or diffuse hyperplasia), endometrial carcinoma, myometrial disorders (adenomyosis, leiomyoma or vascular abnormalities), and adnexal disorders. Color Doppler sonography and hysterosonography are useful complementary tools for ultrasound performance improvement. MR imaging should be performed if TVS is not contributive or is highly recommended for staging of uterine cancers. All these techniques provide useful information for optimal planning treatment.

Objective: To evaluate the role of three-dimensional transvaginal ultrasound in diagnosing endometrial cancer in patients with history of postmenopausal bleeding and compare its effectiveness with two-dimensional ultrasound., Methods: Transvaginal ultrasound examinations, diagnostic hysteroscopy with subsequent curettage, and/or hysterectomy were performed in 213 consecutive patients with a history of postmenopausal bleeding. The results of the ultrasonographic examinations were compared with the diagnoses on the basis of histologic examination. In addition to an explorative data analysis, receiver operating characteristic curves were shown and areas under curves were calculated. Minimal endometrial volume (2.7 ml) and minimal endometrial thickness (7 mm) of endometrial carcinoma were defined as optimal cutoff values., Results: In 42 patients, endometrial carcinoma was diagnosed. The mean endometrial volume of patients with endometrial cancer, measured by three-dimensional ultrasound, was 11.78 ml. The sensitivity of the endometrial volume at the optimal cutoff (2.7 ml) was 100.00%, the specificity was 69.00%, the positive predictive value was 44.20%, and the negative predictive value was 100.00%. On two-dimensional ultrasound, the mean endometrial thickness of patients with endometrial cancer was 16.6 mm. The sensitivity endometrial thickness measurements at the optimal cutoff (7 mm) was 100.00%, the specificity was 43.3%, the positive predictive value was 30.2%, and the negative predictive value was 100.00%. The area under curve of volume measured by three-dimensional ultrasound was 0.89 (95% CI 0.85-0.93). The area under curve of endometrial thickness was 0.85 (95% CI 0.80-0.91). The comparison of the area under curve of receiver operating curves between endometrial volume and endometrial thickness revealed a significant difference (p=0.023)., Conclusion: Volume measurement by three-dimensional transvaginal ultrasound has a higher specificity, which means that it has the ability to better identify the negative cases compared to conventional ultrasound. Three-dimensional transvaginal ultrasound is a helpful tool for diagnosing endometrial cancer in patients with postmenopausal bleeding.

Dysfunctional uterine bleeding is one of the most common reasons patients seek the opinion of a gynecologist. This article reviews the causes of dysfunctional uterine bleeding and the relevant differential diagnosis. Laboratory and radiologic studies pertinent to the evaluation of dysfunctional uterine bleeding are delineated. Medical therapy is the principal tenet of treatment and is summarized for both acute and chronic bleeding. Surgical options are also discussed, as well as treatments of other causes of abnormal uterine bleeding.