Dysfunctional Uterine Bleeding
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Infertility Update
Infertility Update George R Attia, M.D Director of IVF Program University of Texas Southwestern Medical Center at Dallas Infertility • Inability to conceive after one year of adequate unprotected intercourse (six months if the woman is over age 35) Time Required for Conception in Couples Who Will Attain Pregnancy 100 93 95 90 85 80 72 70 nt 57 60 na g 45 e 50 r P 40 % 30 25 20 10 0 1 month 2 months 3 months 6 months 1 Year 2 Year 3 ear 7% 3% 35% Male Factor 20% Tubal Factor Ov dysfunction Unexplained Others 35% 10% 10% 40% Anovulatory Tubal & Pelvic Unusual factors Unexplained 40% • Anovulation • Tubal Factor • Male • Pelvic Factor (Endometriosis, adhesion) • Unexplained • Uterine/cervical (fibroid) 10% PCOS Others 90% Ovulation • History •BBT • LH kits • Mid luteal phase Progesterone (cycle length –7) • Ultrasound • EMB (day 21-26) • Anovulation • Tubal / Pelvic Factor • Male • Unexplained • Uterine/cervical (fibroid) Tubal & Pelvic Factors • Tubal disease, PID • Tubal surgery • Pelvic adhesions • Endometriosis Tubal Factor • Tubal infertility after PID (12%, 24%, 50%) • One-half of patients who found to have tubal damage and/or pelvic adhesion have no history of antecedent disease Tubal Factor • Hysterosalpingography • Hysteroscopy / laparoscopy • Falloscopy • Anovulation • Tubal Factor • Male • Unexplained • Uterine/cervical (fibroid) Male Factor Infertility • Anatomic defects (hypospadias, Retrograde ejac.) • Genetics Causes • Trauma • Infection • Endocrine disorders •Varicocele Male Factor Infertility • Vol. > 2 ml, Conc. > 20x106, -
Polycystic Ovary Syndrome, Oligomenorrhea, and Risk of Ovarian Cancer Histotypes: Evidence from the Ovarian Cancer Association Consortium
Published OnlineFirst November 15, 2017; DOI: 10.1158/1055-9965.EPI-17-0655 Research Article Cancer Epidemiology, Biomarkers Polycystic Ovary Syndrome, Oligomenorrhea, and & Prevention Risk of Ovarian Cancer Histotypes: Evidence from the Ovarian Cancer Association Consortium Holly R. Harris1, Ana Babic2, Penelope M. Webb3,4, Christina M. Nagle3, Susan J. Jordan3,5, on behalf of the Australian Ovarian Cancer Study Group4; Harvey A. Risch6, Mary Anne Rossing1,7, Jennifer A. Doherty8, Marc T.Goodman9,10, Francesmary Modugno11, Roberta B. Ness12, Kirsten B. Moysich13, Susanne K. Kjær14,15, Estrid Høgdall14,16, Allan Jensen14, Joellen M. Schildkraut17, Andrew Berchuck18, Daniel W. Cramer19,20, Elisa V. Bandera21, Nicolas Wentzensen22, Joanne Kotsopoulos23, Steven A. Narod23, † Catherine M. Phelan24, , John R. McLaughlin25, Hoda Anton-Culver26, Argyrios Ziogas26, Celeste L. Pearce27,28, Anna H. Wu28, and Kathryn L. Terry19,20, on behalf of the Ovarian Cancer Association Consortium Abstract Background: Polycystic ovary syndrome (PCOS), and one of its cancer was also observed among women who reported irregular distinguishing characteristics, oligomenorrhea, have both been menstrual cycles compared with women with regular cycles (OR ¼ associated with ovarian cancer risk in some but not all studies. 0.83; 95% CI ¼ 0.76–0.89). No significant association was However, these associations have been rarely examined by observed between self-reported PCOS and invasive ovarian cancer ovarian cancer histotypes, which may explain the lack of clear risk (OR ¼ 0.87; 95% CI ¼ 0.65–1.15). There was a decreased risk associations reported in previous studies. of all individual invasive histotypes for women with menstrual Methods: We analyzed data from 14 case–control studies cycle length >35 days, but no association with serous borderline including 16,594 women with invasive ovarian cancer (n ¼ tumors (Pheterogeneity ¼ 0.006). -
Intermenstrual Bleeding (Bleeding Between Periods)
Intermenstrual Bleeding (Bleeding between periods) What is Intermenstrual bleeding? This is unscheduled bleeding that can occur in between periods. There are many different causes of bleeding between periods but seek medical advice if you are experiencing this, even if it is for reassurance in many situations. What is the nature of bleeding? Bleeding that occurs randomly without any relation to your monthly period should not be ignored, unless the cause is known. The bleeding may be light blood, spotting, a bloody or dark brown vaginal loss or heavy bleeding mimicking a period. Mid cycle pain and bleeding Mittelschmerz is one-sided, lower abdominal pain associated with ovulation, about 14 days before your next menstrual period. In most cases, mittelschmerz does not require medical attention and may be associated with light vaginal bleeding for a day or so. It may not occur every month. If you are concerned, seek advice. Spotting in the lead up to or at the end of the period Usually, this just suggests that levels of progesterone fall slightly more slowly in some cycles and can lead to spotting seen in the lead up to the proper menstrual flow. This is usually not a concern. Spotting or a brown vaginal loss as the period finishes is also not abnormal, unless lasting for days or associated with other symptoms. (See information on a normal menstrual cycle under the leaflet on Irregular Periods) What are the possible causes of bleeding between periods? (not an exhaustive list) Hormonal contraceptives, such as the combined or progesterone only pill, implant, injection, intrauterine system, patch, ring can all cause bleeding between cycles, especially in the first few months of starting them. -
Committee for Monitoring Assisted Reproductive Technology (ICMART) and the World Health Organization (WHO) Revised Glossary on ART Terminology, 2009†
Human Reproduction, Vol.24, No.11 pp. 2683–2687, 2009 Advanced Access publication on October 4, 2009 doi:10.1093/humrep/dep343 SIMULTANEOUS PUBLICATION Infertility The International Committee for Monitoring Assisted Reproductive Technology (ICMART) and the World Health Organization (WHO) Revised Glossary on ART Terminology, 2009† F. Zegers-Hochschild1,9, G.D. Adamson2, J. de Mouzon3, O. Ishihara4, R. Mansour5, K. Nygren6, E. Sullivan7, and S. van der Poel8 on behalf of ICMART and WHO 1Unit of Reproductive Medicine, Clinicas las Condes, Santiago, Chile 2Fertility Physicians of Northern California, Palo Alto and San Jose, California, USA 3INSERM U822, Hoˆpital de Biceˆtre, Le Kremlin Biceˆtre Cedex, Paris, France 4Saitama Medical University Hospital, Moroyama, Saitana 350-0495, JAPAN 53 Rd 161 Maadi, Cairo 11431, Egypt 6IVF Unit, Sophiahemmet Hospital, Stockholm, Sweden 7Perinatal and Reproductive Epidemiology and Research Unit, School Women’s and Children’s Health, University of New South Wales, Sydney, Australia 8Department of Reproductive Health and Research, and the Special Program of Research, Development and Research Training in Human Reproduction, World Health Organization, Geneva, Switzerland 9Correspondence address: Unit of Reproductive Medicine, Clinica las Condes, Lo Fontecilla, 441, Santiago, Chile. Fax: 56-2-6108167, E-mail: [email protected] background: Many definitions used in medically assisted reproduction (MAR) vary in different settings, making it difficult to standardize and compare procedures in different countries and regions. With the expansion of infertility interventions worldwide, including lower resource settings, the importance and value of a common nomenclature is critical. The objective is to develop an internationally accepted and continually updated set of definitions, which would be utilized to standardize and harmonize international data collection, and to assist in monitoring the availability, efficacy, and safety of assisted reproductive technology (ART) being practiced worldwide. -
Diagnostic Evaluation of the Infertile Female: a Committee Opinion
Diagnostic evaluation of the infertile female: a committee opinion Practice Committee of the American Society for Reproductive Medicine American Society for Reproductive Medicine, Birmingham, Alabama Diagnostic evaluation for infertility in women should be conducted in a systematic, expeditious, and cost-effective manner to identify all relevant factors with initial emphasis on the least invasive methods for detection of the most common causes of infertility. The purpose of this committee opinion is to provide a critical review of the current methods and procedures for the evaluation of the infertile female, and it replaces the document of the same name, last published in 2012 (Fertil Steril 2012;98:302–7). (Fertil SterilÒ 2015;103:e44–50. Ó2015 by American Society for Reproductive Medicine.) Key Words: Infertility, oocyte, ovarian reserve, unexplained, conception Use your smartphone to scan this QR code Earn online CME credit related to this document at www.asrm.org/elearn and connect to the discussion forum for Discuss: You can discuss this article with its authors and with other ASRM members at http:// this article now.* fertstertforum.com/asrmpraccom-diagnostic-evaluation-infertile-female/ * Download a free QR code scanner by searching for “QR scanner” in your smartphone’s app store or app marketplace. diagnostic evaluation for infer- of the male partner are described in a Pregnancy history (gravidity, parity, tility is indicated for women separate document (5). Women who pregnancy outcome, and associated A who fail to achieve a successful are planning to attempt pregnancy via complications) pregnancy after 12 months or more of insemination with sperm from a known Previous methods of contraception regular unprotected intercourse (1). -
Epidemiology of Menstrual Disorders in Developing Countries: a Systematic Review
BJOG: an International Journal of Obstetrics and Gynaecology DOI: 10.1046/j.1471-0528.2003.00012.x January 2004, Vol. 111, pp. 6–16 REVIEW Epidemiology of menstrual disorders in developing countries: a systematic review Introduction Information on the prevalence of menstrual complaints in the past three months was obtained in seven countries In developing countries, priority setting in the health (Table 1). These data permit cross national comparisons sector traditionally focuses on the principal causes of mor- in so far as similar questions with a similar time reference tality. More recently, the Global Burden of Disease approach were asked. However, no definitions were provided and incorporates assessment of morbidity and quality of life in considerable variation in the interpretation of questions identifying priorities. Yet, although investigations in various among individuals and across cultures is likely. developing countries reveal that women are concerned by Approximately a dozen subsequent surveys, including menstrual disorders, little attention is paid to understanding community-based, clinic-based and one national census, or ameliorating women’s menstrual complaints.1 Menstrual include some information on menstrual morbidities6–29 dysfunction, like other aspects of sexual and reproductive (Table 2). A few health surveys of special populations, health, is not included in the Global Burden of Disease such as factory workers in Vietnam17 and medical students estimates2,3 and, even as reproductive health programs in Venezuela,27,28 have also included relevant questions expand their focus to address gynaecologic morbidity, the on menstrual disorders. These surveys vary consider- utility of evaluating and treating menstrual problems is ably in the definition of and reference period for men- not generally considered. -
Changes Before the Change1.06 MB
Changes before the Change Perimenopausal bleeding Although some women may abruptly stop having periods leading up to the menopause, many will notice changes in patterns and irregular bleeding. Whilst this can be a natural phase in your life, it may be important to see your healthcare professional to rule out other health conditions if other worrying symptoms occur. For further information visit www.imsociety.org International Menopause Society, PO Box 751, Cornwall TR2 4WD Tel: +44 01726 884 221 Email: [email protected] Changes before the Change Perimenopausal bleeding What is menopause? Strictly defined, menopause is the last menstrual period. It defines the end of a woman’s reproductive years as her ovaries run out of eggs. Now the cells in the ovary are producing less and less hormones and menstruation eventually stops. What is perimenopause? On average, the perimenopause can last one to four years. It is the period of time preceding and just after the menopause itself. In industrialized countries, the median age of onset of the perimenopause is 47.5 years. However, this is highly variable. It is important to note that menopause itself occurs on average at age 51 and can occur between ages 45 to 55. Actually the time to one’s last menstrual period is defined as the perimenopausal transition. Often the transition can even last longer, five to seven years. What hormonal changes occur during the perimenopause? When a woman cycles, she produces two major hormones, Estrogen and Progesterone. Both of these hormones come from the cells surrounding the eggs. Estrogen is needed for the uterine lining to grow and Progesterone is produced when the egg is released at ovulation. -
Abnormal Uterine Bleeding: a Management Algorithm
J Am Board Fam Med: first published as 10.3122/jabfm.19.6.590 on 7 November 2006. Downloaded from EVIDENCED-BASED CLINICAL MEDICINE Abnormal Uterine Bleeding: A Management Algorithm John W. Ely, MD, MSPH, Colleen M. Kennedy, MD, MS, Elizabeth C. Clark, MD, MPH, and Noelle C. Bowdler, MD Abnormal uterine bleeding is a common problem, and its management can be complex. Because of this complexity, concise guidelines have been difficult to develop. We constructed a concise but comprehen- sive algorithm for the management of abnormal uterine bleeding between menarche and menopause that was based on a systematic review of the literature as well as the actual management of patients seen in a gynecology clinic. We started by drafting an algorithm that was based on a MEDLINE search for rel- evant reviews and original research. We compared this algorithm to the actual care provided to a ran- dom sample of 100 women with abnormal bleeding who were seen in a university gynecology clinic. Discrepancies between the algorithm and actual care were discussed during audiotaped meetings among the 4 investigators (2 family physicians and 2 gynecologists). The audiotapes were used to revise the algorithm. After 3 iterations of this process (total of 300 patients), we agreed on a final algorithm that generally followed the practices we observed, while maintaining consistency with the evidence. In clinic, the gynecologists categorized the patient’s bleeding pattern into 1 of 4 types: irregular bleeding, heavy but regular bleeding (menorrhagia), severe acute bleeding, and abnormal bleeding associated with a contraceptive method. Subsequent management involved both diagnostic and treatment interven- tions, which often occurred simultaneously. -
Too Much, Too Little, Too Late: Abnormal Uterine Bleeding
Too much, too little, too late: Abnormal uterine bleeding Jody Steinauer, MD, MAS July, 2015 The Questions • Too much (& too early or too late) – Differential and approach to work‐up – Does she need an endometrial biopsy (EMB)? – Does she need an ultrasound? – How do I stop peri‐menopausal bleeding? – Isn’t it due to the fibroids? • Too fast: She’s hemorrhaging—what do I do? • Too little: A quick review of amenorrhea Case 1 A 46 yo G3P2T1 reports her periods have become 1. What term describes increasingly irregular and heavy her symptoms? over the last 6‐8 months. 2. Physiologically, what Sometimes they come 2 times causes this type of per month and sometimes there bleeding pattern? are 2 months between. LMP 2 3. What is the months ago. She bleeds 10 days differential? with clots and frequently bleeds through pads to her clothes. She occasionally has hot flashes. She also has diabetes and is obese. Q1: In addition to a urine pregnancy test and TSH, which of the following is the most appropriate test to obtain at this time? 1. FSH 2. Testosterone & DHEAS 3. Serum beta‐HCG 4. Transvaginal Ultrasound (TVUS) 5. Endometrial Biopsy (EMB) Terminology: What is abnormal? • Normal: Cycle= 28 days +‐ 7 d (21‐35); Length=2‐7 days; Heaviness=self‐defined • Too little bleeding: amenorrhea or oligomenorrhea • Too much bleeding: Menorrhagia (regular timing but heavy (according to patient) OR long flow (>7 days) • Irregular bleeding: Metrorrhagia, intermenstrual or post‐ coital bleeding • Irregular and Excessive: Menometrorrhagia • Preferred term for non‐pregnant bleeding issues= Abnormal Uterine Bleeding (AUB) – Avoid “DUB” ‐ dysfunctional uterine bleeding. -
Dell Childrens Hospital
DELL CHILDREN’S MEDICAL CENTER EVIDENCE-BASED OUTCOMES CENTER Abnormal Uterine Bleeding Heavy Menstrual Bleeding in Adolescents LEGAL DISCLAIMER: The information provided by Dell Children’s Medical Center of Texas (DCMCT), including but not limited to Clinical Pathways and Guidelines, protocols and outcome data, (collectively the "Information") is presented for the purpose of educating patients and providers on various medical treatment and management. The Information should not be relied upon as complete or accurate; nor should it be relied on to suggest a course of treatment for a particular patient. The Clinical Pathways and Guidelines are intended to assist physicians and other health care providers in clinical decision-making by describing a range of generally acceptable approaches for the diagnosis, management, or prevention of specific diseases or conditions. These guidelines should not be considered inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the same results. The ultimate judgment regarding care of a particular patient must be made by the physician in light of the individual circumstances presented by the patient. DCMCT shall not be liable for direct, indirect, special, incidental or consequential damages related to the user's decision to use this information contained herein. Definition: sexually active, including consensual and coerced sex7. An acute episode of heavy menstrual bleeding is one that, in Specific questions should be asked to determine possibility of the opinion of the clinician, is of sufficient quantity to require bleeding/coagulation disorder (see Table 2 in Addendum 1). immediate intervention to prevent future blood loss1. -
An Intramural Uterine Fibroid Became Submucosal in the Puerperium – Proposed Probable Mechanism: a Case Report Elie Nkwabong
Nkwabong Journal of Medical Case Reports (2018) 12:88 https://doi.org/10.1186/s13256-018-1624-0 CASEREPORT Open Access An intramural uterine fibroid became submucosal in the puerperium – proposed probable mechanism: a case report Elie Nkwabong Abstract Background: Vaginal prolapse of a large uterine fibroid is a rare phenomenon in a woman who delivered vaginally recently, given that this fibroid might have obstructed labor. The author presents a case report of a vaginally prolapsed large pedunculated submucosal uterine myoma in a woman with a recent uncomplicated vaginal delivery. Case presentation: A 25-year-old black African woman had four intramural uterine fibroids of diameters 62 to 94 mm diagnosed in April 2013 with standard ultrasound scan. She got pregnant in July 2014. An ultrasound scan done on 31 August 2014 at 10 weeks’ gestation identified four intramural uterine fibroids, with sizes varying from 70 to 150 mm. Her pregnancy was well followed up, without any complications. She had an uneventful vaginal delivery on 10 April 2015. During uterine exploration, indicated for retention of parts of fetal membranes, no pedunculated submucosal fibroid was found. On 15 May 2015, she consulted for difficult micturition and partial urinary retention that occurred 2 days ago. A vaginally prolapsed 10 cm uterine fibroid was diagnosed. Forty-eight hours after administration of intravenously administered broad spectrum antibiotics, the myoma was successfully twisted off by means of vaginal route under general anesthesia, which relieved her symptoms. Conclusions: To the best of our knowledge, this is the first case of vaginally prolapsed large submucosal uterine fibroid in a woman who delivered vaginally recently. -
Oligo-Anovulation Is Not a Rarer Feature in Women with Documented Endometriosis
Oligo-anovulation is not a rarer feature in women with documented endometriosis Pietro Santulli, M.D., Ph.D.,a,b Chloe Tran, M.D.,a Vanessa Gayet, M.D.,a Mathilde Bourdon, M.D.,a,b Chloe Maignien, M.D.,a Louis Marcellin, M.D.,a,b Khaled Pocate-Cheriet, M.D.,b Charles Chapron, M.D.,a,b and Dominique de Ziegler, M.D.a a Department of Gynaecology Obstetrics II and Reproductive Medicine, Assistance Publique-Hopitaux^ de Paris (AP-HP), Hopital^ Universitaire Paris Centre, Centre Hospitalier Universitaire (CHU) Cochin, Universite Paris Descartes, Sorbonne Paris Cite; and b Department of Development, Reproduction and Cancer, Institut Cochin, INSERM U1016, Universite Paris Descartes, Sorbonne Paris Cite, Paris, France Objective: To study the prevalence of oligo-anovulation in women suffering from endometriosis compared to that of women without endometriosis. Design: A single-center, cross-sectional study. Setting: University hospital-based research center. Patient (s): We included 354 women with histologically proven endometriosis and 474 women in whom endometriosis was surgically ruled out between 2004 and 2016. Intervention: None. Main Outcome Measure(s): Frequency of oligo-anovulation in women with endometriosis as compared to that prevailing in the disease-free reference group. Results: There was no difference in the rate of oligo-anovulation between women with endometriosis (15.0%) and the reference group (11.2%). Regarding the endometriosis phenotype, oligo-anovulation was reported in 12 (18.2%) superficial peritoneal endometriosis, 12 (10.6%) ovarian endometrioma, and 29 (16.6%) deep infiltrating endometriosis. Conclusion(s): Endometriosis should not be discounted in women presenting with oligo-anovulation.