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Fertility and Sterility Oct 2022Iron deficiency (ID) and iron deficiency anemia (IDA) are highly prevalent among women across their life span, especially during the reproductive age. An iron-deficient... (Review)
Review
Iron deficiency (ID) and iron deficiency anemia (IDA) are highly prevalent among women across their life span, especially during the reproductive age. An iron-deficient state has been associated with a number of adverse health consequences, affecting all aspects of the physical and emotional well-being of women. Heavy menstrual bleeding, pregnancy state, and the postpartum period are the major causes of ID/IDA. However, despite the high prevalence and the impact on quality of life, ID/IDA among fertile age women remains underdiagnosed and undertreated. The present Views and Reviews provides an overview on IDA in women's health, describing the background on iron metabolism, heavy menstrual bleeding pathogenetic mechanisms, including a focus on uterine disorders, such as uterine fibroids and adenomyosis. Iron replacement therapies, patient blood management, and treatment options for uterine disorders also are explored.
Topics: Anemia, Iron-Deficiency; Female; Humans; Iron; Iron Deficiencies; Menorrhagia; Pregnancy; Quality of Life; Reproductive Health; Women's Health
PubMed: 36182259
DOI: 10.1016/j.fertnstert.2022.08.850 -
The Medical Clinics of North America Mar 2023Abnormal uterine bleeding is a common problem in premenopausal women and refers to uterine bleeding that is abnormal in frequency, duration, volume, and/or regularity.... (Review)
Review
Abnormal uterine bleeding is a common problem in premenopausal women and refers to uterine bleeding that is abnormal in frequency, duration, volume, and/or regularity. Etiologies can be classified using the PALM-COIEN system. Patients should receive a comprehensive history and physical with special attention to menstrual, sexual, and family history. Physical examination needs to include a pelvic examination with speculum and bimanual components. All patients need to have a pregnancy test and CBC with platelets. Treatments vary by etiology. Medical treatments include levonorgestrel intrauterine devices, oral contraceptive pills, and tranexamic acid. Surgical treatment options include endometrial ablation and hysterectomy.
Topics: Pregnancy; Humans; Female; Menorrhagia; Levonorgestrel; Uterine Hemorrhage; Contraceptives, Oral; Hysterectomy
PubMed: 36759094
DOI: 10.1016/j.mcna.2022.10.014 -
Seminars in Reproductive Medicine May 2020Adenomyosis is a common disorder of the uterus, and is associated with an enlarged uterus, heavy menstrual bleeding (HMB), pelvic pain, and infertility. It is... (Review)
Review
Adenomyosis is a common disorder of the uterus, and is associated with an enlarged uterus, heavy menstrual bleeding (HMB), pelvic pain, and infertility. It is characterized by endometrial epithelial cells and stromal fibroblasts abnormally found in the myometrium where they elicit hyperplasia and hypertrophy of surrounding smooth muscle cells. While both the mechanistic processes and the pathogenesis of adenomyosis are uncertain, several theories have been put forward addressing how this disease develops. These include intrinsic or induced (1) microtrauma of the endometrial-myometrial interface; (2) enhanced invasion of endometrium into myometrium; (3) metaplasia of stem cells in myometrium; (4) infiltration of endometrial cells in retrograde menstrual effluent into the uterine wall from the serosal side; (5) induction of adenomyotic lesions by aberrant local steroid and pituitary hormones; and (6) abnormal uterine development in response to genetic and epigenetic modifications. Dysmenorrhea, HMB, and infertility are likely results of inflammation, neurogenesis, angiogenesis, and contractile abnormalities in the endometrial and myometrial components. Elucidating mechanisms underlying the pathogenesis of adenomyosis raise possibilities to develop targeted therapies to ameliorate symptoms beyond the current agents that are largely ineffective. Herein, we address these possible etiologies and data that support underlying mechanisms.
Topics: Adenomyosis; Animals; Cell Movement; Dysmenorrhea; Endometrium; Female; Humans; Infertility, Female; Menorrhagia; Myometrium
PubMed: 33032339
DOI: 10.1055/s-0040-1716687 -
Best Practice & Research. Clinical... Nov 2020This chapter explores the role of progesterone and progestogens in the management of abnormal uterine bleeding (AUB). Progestogens are used to regulate intermenstrual... (Review)
Review
This chapter explores the role of progesterone and progestogens in the management of abnormal uterine bleeding (AUB). Progestogens are used to regulate intermenstrual bleeding and decrease heavy menstrual bleeding (HMB) in women of reproductive age or who are perimenopausal. In menopausal women, progesterones and progestogens prevent endometrial hyperplasia and aim to reduce the development of endometrial cancer. We hope to make clear current best practice including preparation, specific benefits and risks. Progesterone also acts in concert with other hormones to affect breast, cardiovascular system, lipid profile and bone. We hope to explain how its unintended side effects may be used beneficially or may cause intended side effects.
Topics: Female; Humans; Menorrhagia; Metrorrhagia; Progesterone; Progestins; Uterine Hemorrhage
PubMed: 32698992
DOI: 10.1016/j.bpobgyn.2020.05.004 -
American Journal of Obstetrics and... Jul 2023For reproductive-aged women, the symptom of heavy menstrual bleeding is highly prevalent and a major contributor to iron deficiency and its most severe manifestation,... (Review)
Review
For reproductive-aged women, the symptom of heavy menstrual bleeding is highly prevalent and a major contributor to iron deficiency and its most severe manifestation, iron deficiency anemia. It is recognized that these 2 clinical entities are not only highly prevalent, but their interrelationship is poorly appreciated and frequently normalized by society, healthcare providers, and affected girls and women themselves. Both heavy menstrual bleeding and iron deficiency, with or without anemia, adversely impact quality of life-heavy menstrual bleeding during the episodes of bleeding and iron deficiency on a daily basis. These combined issues adversely affect the lives of reproductive-aged girls and women of all ages, from menarche to menopause, and their often-insidious nature frequently leads to normalization. The effects on cognitive function and the related work and school absenteeism and presenteeism can undermine the efforts and function of women in all walks of life, be they students, educators, employers, or employees. There is also an increasing body of evidence that suggests that iron deficiency, even in early pregnancy, may adversely impact fetal neurodevelopment with enduring effects on a spectrum of cognitive and psychological disorders, critically important evidence that begs the normalization of iron stores in reproductive-aged women. The authors seek to raise individual, societal, and professional awareness of this underappreciated situation in a fashion that leads to meaningful and evidence-based changes in clinical guidance and healthcare policy directed at preventing, screening, diagnosing, and appropriately managing both disorders. This manuscript provides evidence supporting the need for action and describes the elements necessary to address this pervasive set of conditions that not only affect reproductive-aged girls and women but also the lives of children everywhere.
Topics: Pregnancy; Child; Female; Humans; Adult; Anemia, Iron-Deficiency; Menorrhagia; Quality of Life; Iron Deficiencies; Iron
PubMed: 36706856
DOI: 10.1016/j.ajog.2023.01.017 -
Journal of Obstetrics and Gynaecology... Jun 2023To describe the current evidence-based diagnosis and management of adenomyosis.
OBJECTIVE
To describe the current evidence-based diagnosis and management of adenomyosis.
TARGET POPULATION
All patients with a uterus of reproductive age.
OPTIONS
Diagnostic options include transvaginal sonography and magnetic resonance imaging. Treatment options should be tailored to symptoms (heavy menstrual bleeding, pain, and/or infertility) and include medical options (non-steroidal anti-inflammatory drugs, tranexamic acid, combined oral contraceptives, levonorgestrel intrauterine system, dienogest, other progestins, gonadotropin-releasing analogues), interventional options (uterine artery embolization), and surgical options (endometrial ablation, excision of adenomyosis, hysterectomy).
OUTCOMES
Outcomes of interest include reduction in heavy menstrual bleeding, reduction in pelvic pain (dysmenorrhea, dyspareunia, chronic pelvic pain), and improvement in reproductive outcomes (fertility, miscarriage, adverse pregnancy outcomes).
BENEFITS, HARMS, AND COSTS
This guideline will benefit patients with gynaecological complaints that may be caused by adenomyosis, especially those patients who wish to preserve their fertility, by presenting diagnostic methods and management options. It will also benefit practitioners by improving their knowledge of various options.
EVIDENCE
Databases searched were MEDLINE Reviews, MEDLINE ALL, Cochrane, PubMed, EMBASE. The initial search was completed in 2021 and updated with relevant articles in 2022. Search terms included adenomyosis, adenomyoses, endometritis (used/indexed as adenomyosis before 2012), (endometrium AND myometrium) uterine adenomyosis/es, symptom/s/matic adenomyosis] AND [diagnosis, symptoms, treatment, guideline, outcome, management, imaging, sonography, pathogenesis, fertility, infertility, therapy, histology, ultrasound, review, meta-analysis, evaluation]. Articles included randomized controlled trials, meta-analyses, systematic reviews, observational studies, and case reports. Articles in all languages were searched and reviewed.
VALIDATION METHODS
The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Table A1 for definitions and Table A2 for interpretations of strong and conditional [weak] recommendations).
INTENDED AUDIENCE
Obstetrician-gynaecologists, radiologists, family physicians, emergency physicians, midwives, registered nurses, nurse practitioners, medical students, residents, and fellows.
TWEETABLE ABSTRACT
Adenomyosis is common in reproductive-aged women. There are diagnostic and management options that preserve fertility available.
SUMMARY STATEMENTS
RECOMMENDATIONS.
Topics: Adult; Female; Humans; Pregnancy; Adenomyosis; Infertility; Menorrhagia; Pelvic Pain; Uterus
PubMed: 37244746
DOI: 10.1016/j.jogc.2023.04.008 -
The Medical Journal of Malaysia May 2022Abnormal uterine bleeding (AUB) is one of the commonest complaints of women in reproductive age and non-gravid state that brings them to the attention of the primary...
Abnormal uterine bleeding (AUB) is one of the commonest complaints of women in reproductive age and non-gravid state that brings them to the attention of the primary care doctor or the gynaecologist. Anovulation without any medical illness or pelvic pathology seems to be the common cause. Bleeding due to a wide variation in pathology both inside and outside the reproductive tract can be termed as anovulatory bleeding. Therefore, it is mandatory to elicit a focused menstrual history and appropriate evaluation followed by a pelvic examination. This includes a vaginal speculum examination to differentiate anovulatory bleeding from other causes of bleeding. In contrast, Heavy menstrual bleeding (HMB) is referred to as an ovulatory bleeding exceeding 8 days duration and is often caused by uterine fibroids or adenomyosis, a copper IUD or coagulation disorders. PALM-COEIN classification is a system designed by the Federation Internationale de Gynaecologie et d'Obstetrique to define the precise underlying causes of AUB. Aetiology of AUB can be classified as the following acronym "PALM-COEIN": Polyp, Adenomyosis, Leiomyoma, Malignancy and hyperplasia, Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic and Not yet classified. AUB describes a range of symptoms, such as HMB, intermenstrual bleeding (IMB) and a combination of both heavy and prolonged menstrual bleeding (MB). Dysfunctional uterine bleeding (DUB) and menorrhagia are now better described as AUB. Newborn girls sometimes spot for a few days after birth, due to placental oestrogenic stimulation of the endometrium in utero.
Topics: Adenomyosis; Female; Humans; Infant, Newborn; Leiomyoma; Menorrhagia; Placenta; Pregnancy; Uterine Hemorrhage
PubMed: 35638495
DOI: No ID Found -
International Journal of Environmental... Jan 2021The aim of this review is to clarify the relative association between adenomyosis and infertility and the possible treatment for an infertile patient. Although... (Review)
Review
The aim of this review is to clarify the relative association between adenomyosis and infertility and the possible treatment for an infertile patient. Although adenomyosis is detected more often in women of late reproductive age, its influence on pregnancy rates is important, especially considering the tendency to delay pregnancy among women in developed countries. In this article, we present a critical analysis of the literature data concerning the impact of adenomyosis on fertility. The possible effects of treatment on the pregnancy rate will also be discussed. We conducted a literature search; publications from Pubmed, Embase and Cochrane databases published from 1982 to 2019 were retrieved using terms 'adenomyosis and infertility' and 'adenomyosis and pregnancy outcomes', extensively studied in the aspects of diagnosis, pathogenesis of infertility and possible treatment methods. Molecular studies have given deep insight into the pathogenesis of adenomyosis in the recent few years, but there is a huge discrepancy between in vitro studies and praxis. Oral contraceptive pills, anti-prostaglandins, oral or parenteral progestins, danazol and gonadotrophin-releasing hormone (GnRH) analogues have all been used to control menstrual pain and menorrhagia in women with adenomyosis, but they temporarily suppress the menstrual cycle. Additionally, endometrial ablation and hysterectomy used to alleviate pain caused by adenomyosis exclude pregnancy planning. The development of imaging techniques-ultrasound and MRI-enables the diagnosis of adenomyosis with very high accuracy nowadays, but the methods of treatment mentioned above have not given satisfactory results in women planning pregnancy. For these patients, the high-intensity-focused ultrasound method (HIFU) and combined treatment before assisted reproductive techniques can prove beneficial in adenomyosis patients.
Topics: Adenomyosis; Dysmenorrhea; Female; Humans; Infertility; Menorrhagia; Pregnancy; Pregnancy Rate
PubMed: 33573117
DOI: 10.3390/ijerph18031235 -
The New England Journal of Medicine Feb 2021Uterine fibroids are a common cause of heavy menstrual bleeding and pain. Treatment with the combination of relugolix (an oral gonadotropin-releasing hormone-receptor... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Uterine fibroids are a common cause of heavy menstrual bleeding and pain. Treatment with the combination of relugolix (an oral gonadotropin-releasing hormone-receptor antagonist), estradiol, and norethindrone acetate, administered once daily, may have efficacy in women with uterine fibroids and heavy bleeding while avoiding hypoestrogenic effects.
METHODS
We conducted two replicate international, double-blind, 24-week, phase 3 trials involving women with fibroid-associated heavy menstrual bleeding. Participants were randomly assigned in a 1:1:1 ratio to receive once-daily placebo, relugolix combination therapy (40 mg of relugolix, 1 mg of estradiol, and 0.5 mg of norethindrone acetate), or delayed relugolix combination therapy (40 mg of relugolix monotherapy, followed by relugolix combination therapy, each for 12 weeks). The primary efficacy end point in each trial was the percentage of participants with a response (volume of menstrual blood loss <80 ml and a ≥50% reduction in volume from baseline) in the relugolix combination therapy group, as compared with the placebo group. Key secondary end points were amenorrhea, volume of menstrual blood loss, distress from bleeding and pelvic discomfort, anemia, pain, fibroid volume, and uterine volume. Safety and bone mineral density were assessed.
RESULTS
A total of 388 women in trial L1 and 382 in trial L2 underwent randomization. A total of 73% of the participants in the relugolix combination therapy group in trial L1 and 71% of those in trial L2 had a response (primary end point), as compared with 19% and 15%, respectively, of those in the placebo groups (P<0.001 for both comparisons). Both relugolix combination therapy groups had significant improvements, as compared with the placebo groups, in six of seven key secondary end points, including measures of menstrual blood loss (including amenorrhea), pain, distress from bleeding and pelvic discomfort, anemia, and uterine volume, but not fibroid volume. The incidence of adverse events was similar with relugolix combination therapy and placebo. Bone mineral density was similar with relugolix combination therapy and placebo but decreased with relugolix monotherapy.
CONCLUSIONS
Once-daily relugolix combination therapy resulted in a significant reduction in menstrual bleeding, as compared with placebo, and preserved bone mineral density in women with uterine fibroids. (Funded by Myovant Sciences; LIBERTY 1 [L1] and LIBERTY 2 [L2] ClinicalTrials.gov numbers, NCT03049735 and NCT03103087, respectively.).
Topics: Adult; Double-Blind Method; Drug Combinations; Drug Therapy, Combination; Estradiol; Estrogens; Female; Hot Flashes; Humans; Leiomyoma; Menorrhagia; Middle Aged; Norethindrone Acetate; Phenylurea Compounds; Pyrimidinones; Uterine Neoplasms; Young Adult
PubMed: 33596357
DOI: 10.1056/NEJMoa2008283 -
American Family Physician Jan 2022Adenomyosis is a clinical condition where endometrial glands are found in the myometrium of the uterus. One in three patients with adenomyosis is asymptomatic, but the...
Adenomyosis is a clinical condition where endometrial glands are found in the myometrium of the uterus. One in three patients with adenomyosis is asymptomatic, but the rest may present with heavy menstrual bleeding, pelvic pain, or infertility. Heavy menstrual bleeding is the most common symptom. Adenomyosis is distinct from endometriosis (the presence of endometrial glands outside of the uterus), but the two conditions often occur simultaneously. Risk factors for developing adenomyosis include increasing age, parity, and history of uterine procedures. Most patients are diagnosed from 40 to 50 years of age, but younger patients with infertility are increasingly being diagnosed with adenomyosis as imaging modalities improve. Diagnosis of adenomyosis begins with clinical suspicion and is confirmed with transvaginal ultrasonography and pelvic magnetic resonance imaging. Treatment of adenomyosis typically starts with hormonal menstrual suppression. Levonorgestrel-releasing intrauterine systems have shown some effectiveness. Patients with adenomyosis may ultimately have a hysterectomy if symptoms are not controlled with medical therapy.
Topics: Adenomyosis; Adult; Contraceptive Agents, Hormonal; Endometriosis; Female; Humans; Hysterectomy; Infertility; Intrauterine Devices, Medicated; Levonorgestrel; Magnetic Resonance Imaging; Menorrhagia; Middle Aged; Pelvic Pain; Pregnancy; Risk Factors; Ultrasonography
PubMed: 35029928
DOI: No ID Found