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OBJECTIVE: To examine symptom severity and duration at time of referral to secondary care for heavy menstrual bleeding (HMB) by socioeconomic deprivation, age and ethnicity DESIGN: Cohort analysis of data from the National HMB Audit linked to Hospital Episode Statistics data. SETTING: English and Welsh National Health Services (secondary care): February 2011 to January 2012. PARTICIPANTS: 15 325 women aged 18-60 years in England and Wales who had a new referral for HMB to a gynaecology outpatient department METHODS: Multivariable linear regression to calculate adjusted differences in mean symptom severity and quality of life scores at first outpatient visit. Multivariable logistic regression to calculate adjusted ORs. Adjustment for body mass index, parity and comorbidities. PRIMARY OUTCOME MEASURES: Mean symptom severity score (0=best, 100=worst), mean condition-specific quality of life score (0=worst, 100=best) and symptom duration (≥1 year). RESULTS: Women were on average 42 years old and 12% reported minority ethnic backgrounds. Mean symptom severity and condition-specific quality of life scores were 61.8 and 34.7. Almost three-quarters of women (74%) reported having had symptoms for ≥1 year. Women from more deprived areas had more severe symptoms at their first outpatient visit (difference -6.1; 95% CI-7.2 to -4.9, between least and most deprived quintiles) and worse condition-specific quality of life (difference 6.3; 95% CI 5.1 to 7.5). Symptom severity declined with age while quality of life improved. CONCLUSIONS: Women living in more deprived areas reported more severe HMB symptoms and poorer quality of life at the start of treatment in secondary care. Providers should examine referral practices to explore if these differences reflect women's health-seeking behaviour or how providers decide whether or not to refer.

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Heavy menstrual bleeding (HMB) is a common gynecological complaint with multiple etiologies and diverse pathophysiological origins. This review discusses HMB with reference to the recently proposed PALM-COEIN classification system for abnormal uterine bleeding, initially describing the endometrial events in normal menstruation followed by discussion of the perturbations of normal endometrial shedding that can result in HMB. Our present understanding of the mechanisms of menstrual bleeding as well as many of the pathological aberrations of HMB is incomplete. Further research into the pathophysiology of HMB is urgently needed, as clear knowledge of the mechanisms of this disorder will provide new therapeutic targets to formulate more effective treatments.

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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.

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OBJECTIVE: A dichotomy exists within the treatment of heavy menstrual bleeding (HMB); guidelines and expert opinion recommend that clinical management be guided by subjective, patient-centered measures, yet clinical trials often describe treatment efficacy in terms of objective reductions in menstrual blood loss (MBL). The purpose of this investigation was to correlate subjective and objective aspects of HMB treatment by identifying the minimum change in MBL that would be considered meaningful to women. RESEARCH DESIGN AND METHODS: Receiver operating characteristic (ROC) curve analyses were performed using data from a multicenter, randomized, double-blind, placebo-controlled, parallel-group study of a novel, oral formulation of tranexamic acid (Lysteda). The study enrolled women ages 18-49 years with a history of cyclic HMB. Menstrual blood loss was measured objectively using the alkaline hematin method and subjectively using the Menorrhagia Impact Questionnaire (MIQ), a patient-reported outcome instrument previously validated in an HMB population. Additional subgroup analyses were performed after stratification by low (80-160 mL/cycle) or high (> 160 mL/cycle) baseline MBL. CLINICAL TRIAL REGISTRATION: NCT00401193 (NIH Clinical Trials Registry) RESULTS: A total of 278 women were included in the ROC analyses. The best balance of sensitivity and specificity was achieved for predicting a patient-perceived meaningful improvement in MBL, at a cut point of 36 mL/cycle. Absolute reductions in MBL that were considered meaningful were more modest in women with lower baseline MBL (22 mL/cycle) and greater in women with higher baseline MBL (47 mL/cycle). However, an approximately 22% MBL reduction was meaningful to the majority of women in either the low or high baseline MBL subgroups. CONCLUSIONS: Reducing measurable MBL by 36 mL/cycle, or approximately 22%, was considered to be a meaningful improvement for the majority of women with HMB in this study population.

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PURPOSE OF REVIEW: This review highlights the difficulties currently caused by the ill-defined and confused use of terminologies to describe symptoms, signs and causes of abnormal uterine bleeding. It also attempts to put usage of modern terminologies in an historical context with important lessons for current usage. RECENT FINDINGS: Confused terminology has led to difficulties in interpreting the results of many clinical trials of new therapies and surgical procedures for abnormal uterine bleeding, and in understanding some studies investigating underlying mechanisms of bleeding. The confusion is so great that a major international expert group has recommended abolition of such terms as 'menorrhagia', 'metrorrhagia' and 'dysfunctional uterine bleeding', and replacement with much simpler terms to specifically cover cycle regularity, frequency, duration and heaviness of bleeding episodes, and to acknowledge a significant change in pattern for individual women. New terminologies are required to describe certain underlying causes of abnormal uterine bleeding. SUMMARY: Such discussion should be an ongoing process aimed towards good international agreement, which will greatly simplify the interpretation of clinical trials and scientific studies of mechanisms and treatment responses, and will contribute to the process of education at all levels.

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BACKGROUND: There is considerable worldwide confusion in the use of terminologies and definitions around the symptom of abnormal uterine bleeding, and these are leading increasingly to difficulties in setting up multinational clinical trials and in interpreting the results of studies undertaken in single centers. OBJECTIVE: To develop an agreement process through an international initiative to recommend clear, simple terminologies and definitions that have the potential for wide acceptance. DESIGN: After widespread consultation with relevant international and national organizations, journal editors, and individuals, a modified Delphi process was developed to assess current use of terminologies, followed by a structured face-to-face meeting of 35 clinicians (mostly gynecologists) and scientists in Washington, DC. Focused small-group discussions led to plenary assessment of concepts and recommendations by using an electronic keypad voting system. SETTING: An international group of experts on disorders of menstruation. PATIENT(S): Women with complaint of menstrual symptoms. INTERVENTION(S): An international debate and consultation process. MAIN OUTCOME MEASURE(S): Expert debate and anonymous voting on agreement through use of electronic keypads. RESULT(S): There was almost-universal agreement that poorly defined terms of classical origin that are used in differing ways in the English medical language should be discarded and that these should be replaced by simple, descriptive terms with clear definitions that have the potential to be understood by health professionals and patients alike and that can be translated into most languages. The major recommendations were to replace terms such as menorrhagia, metrorrhagia, hypermenorrhea, and dysfunctional uterine bleeding. Suggestions for potentially suitable replacement terms and definitions are made. CONCLUSION(S): A simple terminology has been recommended for the description and definition of symptoms and signs of abnormal uterine bleeding. This article should be a living document and should be part of an ongoing process with international medical and community debate. Classification of causes, investigations, and cultural and quality-of-life issues should be part of the ongoing process.

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This guideline covers assessing and managing heavy menstrual bleeding (menorrhagia). It aims to help healthcare professionals investigate the cause of heavy periods that are affecting a woman's quality of life and to offer the right treatments, taking into account the woman's priorities and preferences. This guideline includes updated recommendations on: investigations for the cause of heavy menstrual bleeding; and management of heavy menstrual bleeding. It also includes recommendations on: history, physical examination and tests; and information for women.

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OBJECTIVE: Menorrhagia is defined in terms of statistical"abnormality"as blood loss of >80 mL. We examined the usefulness of this definition in women who were referred to gynecology clinics with heavy periods. STUDY DESIGN: A questionnaire survey of 952 menstrual complaint referrals at 3 hospital gynaecology clinics in Glasgow and Edinburgh included 226 women with heavy periods who had also consented to the measurement of their blood loss. RESULTS: Women reported a range of problems with their periods, but absolute volume (31.2%) was less prevalent than period pain (37.5%), mood change (35.7%), and change in the amount (volume) of the period (33.8%). Although there were associations with volume, these associations were due to the heaviest and lightest of the loss groups, whereas the 2 groups with loss either side of 80 mL were virtually indistinguishable. CONCLUSION: The 80-mL criterion for menorrhagia is of limited clinical usefulness because it is prognostic neither for problems nor iron status and apparently does not guide management.

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Forty-five women with a chief complaint of abnormal vaginal bleeding from a few days' duration (spotting) to three to six months of bleeding (average, 4.5 months) were evaluated using a standard clinical approach followed by transvaginal ultrasound (US). Serum estradiol (E2), progesterone and/or endometrial biopsy was used to further clarify the etiology of the bleeding and confirm the clinical or ultrasound diagnosis. Anatomic findings were present in 31% of patients by US examination as compared to only 9% by clinical evaluation. An additional 9% of patients had polycystic ovary disease. Of the 16% of study patients on oral contraceptives with a clinical diagnosis of breakthrough bleeding, 33% had anatomic findings associated with the bleeding on US. The ultrasound image of the endometrium predicted the endometrial biopsy findings in all three patients with postmenopausal bleeding. In the remaining patients with a diagnosis of dysfunctional uterine bleeding (DUB) (a diagnosis usually made clinically by excluding other etiologies), US was helpful in excluding many patients with anatomic findings not detected by physical examination and in evaluating the endometrium, helping differentiate anovulatory from ovulatory DUB. US was helpful in predicting the hormonal and histologic endometrial status of the patients. Patients with more severe and prolonged DUB had low serum E2 with US findings of a single-line endometrium (consistent with low serum E2 and anovulation). US can be a valuable aid in evaluating women presenting with a complaint of abnormal vaginal bleeding by demonstrating anatomic findings frequently not discernible on pelvic examination, such as small cysts and leiomyomas and even endometrial carcinoma, and in evaluating the endometrium in terms of its thickness and, indirectly, the endometrial histology and the ovulatory and hormonal status of the patient. US can also be of value in confirming some diagnoses that are generally made clinically by exclusion, such as breakthrough bleeding from oral contraceptive use and DUB.

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Forty-six patients with the diagnosis of menometrorrhagia, currently under control in the infantile and adolescent unit of Obstetrics and Gynecology Hospital del Salvador. We emphasize that uterine hemorrhage is a frequent emergency during adolescence requiring fully studies. Medical treatment using different hormonal schemes solve the majority of menometrorrhagias. Only a small group require a D & C using the virginal approach. Patients should be controlled during various cycles once bleeding is stopped to avoid relapse and future problems related with anovulation, endometrial hyperplasia or fertility problems.

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PIP: A review of the organic and hormonal causes of irregular menstrual bleeding is presented. Menstrual bleeding irregularities are the most frequent gynecological ailment. Oligomenorrhea is most often caused by a prolonged proliferation phase in the menstrual cycle. In younger women this may be due to insufficient hormonal secretion of the pituitary gland; in older women it may be due to late follicular development in spite of normal glandular secretion. Polymenorrhea is usually caused in younger women by a shortening of the proliferation phase, usually because the ovaries are hypersensitive to pituitary hormones, which causes an aceleration of follicular development. Polymenorrhea in older women is usually due to a shortened secretory phase caused by early degeneration of the corpus luteum, and later may develop into oligomenorrhea or amenorrhea. Irregular corpus luteum function after ovulation can cause bleeding irregularities. When the corpus luteum fails to produce progesterone, the endometrium develops irregularly, causing premenstural spotting or increased volume of menstrual bleeding. Slow degeneration of the corpus luteum causes increased progesterone production and irregular discharge of the endometrium. Anovulation is the most frequent cause of bleeding irregularities, because there is no progesterone secretion. A quick increase in estrogen production in the proliferation phase in conjunction with anovulation causes an irregular discharging of the endometrium with prolonged or increased bleeding. A slow increase in estrogen production during the proliferation phase in conjunction with anovulation causes hyperplasia. In a few patients, anovulation in conjunction with a secretion of estrogen insufficient to maintain the endometrium can cause endometrial atrophy. Irregular bleeding is usually functional in younger women and organic in older women. To diagnose the cause of irregular menstrual bleeding, organic reasons should be explored 1st. A complete history should be taken, then abrasio, recording the basal temperature, and hematological, and hormonal analysis should be used to pinpoint the causes of irregular bleeding. Abrasio is the most common treatment for bleeding irregularities, and hormone treatment is the 2nd most common. Hysterectomy should be used only in extreme cases for treatment of bleeding irregularities.^ieng

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