The medical management of abnormal uterine bleeding in reproductive-aged women.

In the treatment of women with abnormal uterine bleeding, once a thorough history, physical examination, and indicated imaging studies are performed and all significant structural causes are excluded, medical management is the first-line approach. Determining the acuity of the bleeding, the patient\u27s medical history, assessing risk factors, and establishing a diagnosis will individualize their medical regimen. In acute abnormal uterine bleeding with a normal uterus, parenteral estrogen, a multidose combined oral contraceptive regimen, a multidose progestin-only regimen, and tranexamic acid are all viable options, given the appropriate clinical scenario. Heavy menstrual bleeding can be treated with a levonorgestrel-releasing intrauterine system, combined oral contraceptives, continuous oral progestins, and tranexamic acid with high efficacy. Nonsteroidal antiinflammatory drugs may be utilized with hormonal methods and tranexamic acid to decrease menstrual bleeding. Gonadotropin-releasing hormone agonists are indicated in patients with leiomyoma and abnormal uterine bleeding in preparation for surgical interventions. In women with inherited bleeding disorders all hormonal methods as well as tranexamic acid can be used to treat abnormal uterine bleeding. Women on anticoagulation therapy should consider using progestin-only methods as well as a gonadotropin-releasing hormone agonist to treat their heavy menstrual bleeding. Given these myriad options for medical treatment of abnormal uterine bleeding, many patients may avoid surgical intervention

Vulvar endometriosis presenting with dyspareunia: a case report.

BACKGROUND: Superficial dyspareunia can be caused by a multitude of medical and psychological conditions, including pathologic conditions of the vulva. Although infectious and inflammatory causes are more common, vulvar endometriosis is a rare and often overlooked etiology of dyspareunia. CASE: A 33-year-old woman, gravida 1, para 1, presented for a gynecologic consultation with a 2-year history of increasing dyspareunia and cyclical vulvar pain associated with a vulvar mass. Previous treatment with analgesics and sitz baths did not alleviate the symptoms. Pelvic examination revealed a right Bartholin\u27s gland mass that was tender to palpation. The working diagnosis was a Bartholin\u27s cyst as the cause of the dyspareunia, and the patient was scheduled for marsupialization and/or resection. Examination under anesthesia revealed an irregular, 5 cm, solid mass that extended into the labia majora, which was excised. Pathologic examination of the mass revealed endometriosis. The postoperative course was unremarkable and the patient reported complete resolution of symptoms. CONCLUSION: This case illustrates that superficial dyspareunia associated with cyclical vulvar pain can be caused by endometriosis involving the labia majora

Versatility of the suprapubic port in robotic assisted laparoscopic myomectomy.

OBJECTIVE: To demonstrate the multiple advantages of the suprapubic port in robotic assisted laparoscopic myomectomy. DESIGN: Video demonstration of a robotic assisted laparoscopic myomectomy technique using a suprapubic incisional retractor (GelPOINT). SETTING: Hospital. PATIENT(S): A 32-year-old primigravid women with heavy menstrual bleeding and pelvic pain with a 12-cm leiomyoma (International Federation of Gynecology and Obstetrics type 5). INTERVENTION(S): Illustrate a surgical approach during robotic assisted laparoscopic myomectomy with the use of a 5-cm suprapubic incision, an incisional retractor (GelPOINT) for the enucleation, and extraction of a large leiomyoma. MAIN OUTCOME MEASURE(S): The effective enucleation and extraction of a leiomyoma specimen using an incisional retractor and GelPOINT. The steps of the technique and the role of GelPOINT are demonstrated. RESULT(S): The procedure was performed without incident, and the patient experienced pain relief and lighter menses postoperatively. This technique has been performed successfully since June 2014 on 22 women. CONCLUSION(S): During a robotic assisted laparoscopic myomectomy the suprapubic incision is both advantageous and practical. The small incision allows the surgery to remain minimally invasive; the primary umbilical trocar is inserted under direct visualization in an already insufflated abdomen; the location of the incision allows the surgical assistant easy access to the port; the passing of the needles occurs under direct visualization with minimal camera manipulation; and last, the extraction of large tissue can be performed within a specimen pouch through this same suprapubic incision in a short period

Minimally Invasive Approaches to Myoma Management.

Patients affected by the presence of leiomyomas may incur a substantial physical, emotional, social, and financial toll as well as losses in their quality of life. Although many myomas are not amenable to medical therapy or hysteroscopic resection, many others are amenable to minimally invasive surgical approaches. In patients who prefer to retain their fertility, laparoscopic myomectomy should be considered the intervention of choice. In this review, we expand on the surgical techniques of both conventional laparoscopic and robotic-assisted myomectomies. We discuss port placement, enucleation of myomas, tissue extraction, minimization of blood loss, adhesion prevention, and the technique for closure of uterine incisions. Finally, we discuss the available data supporting the use of these 2 approaches as the preferred, safe, and effective fertility-sparing surgical option. We also briefly discuss the emerging technologies of uterine artery embolization, ultrasound surgery, and radiofrequency ablation

Family planning attitudes of medically underserved Latinas.

OBJECTIVE: To evaluate the cultural and socioeconomic factors that may influence family planning decisions in Latinas attending a community health center. METHODS: Contraceptive choices made by medically underserved Latinas attending a federally funded community health clinic were surveyed, and the societal, religious, economic, and community factors that affect their use were evaluated. RESULTS: In a cohort of 97 Latinas, almost one third were not using birth control, and those using birth control often chose nonhormonal methods. Early pregnancy was desired by this cohort, with 72 women (84%) reporting that 25 years or younger was an ideal age for a first pregnancy; 81 women (89 %) indicated having children was an extremely important goal for them. CONCLUSIONS: Contraceptive use was lower than the national average in this cohort of mainly Spanish-speaking Latinas, with most of the women using methods considered not as efficacious as hormonal ones. These data suggest that initial counseling for young Latinas, especially for those who may not be acclimated to U.S. culture as evidenced by their preference for counseling in Spanish, should focus on how to optimally prepare for planning and spacing of pregnancies rather than on how to prevent pregnancy. Counseling that emphasizes only birth control options and not pregnancy concerns should be employed after desired family size is reached

Uniparental disomy in the human blastocyst is exceedingly rare.

OBJECTIVE: To establish whether uniparental disomy (UPD) could represent an outcome of embryonic aneuploidy self-correction and its relevance to preimplantation genetic diagnosis, and to validate a method of UPD detection in limited quantities of cells and determine the frequency of UPD in a large sample size of human blastocysts. DESIGN: Retrospective observational. SETTING: Academic center for reproductive medicine. PATIENT(S): Couples undergoing in vitro fertilization (IVF) treatment whose embryos underwent trophectoderm biopsy single-nucleotide polymorphism (SNP) array-based 24-chromosome aneuploidy screening. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Rate of UPD observed in the human blastocyst. RESULT(S): After application of defined thresholds, 2 of 3,401 blastocysts were found to possess isodisomy, and 0 were found to possess heterodisomy. The overall frequency of UPD in the human blastocyst was therefore 0.06%. CONCLUSION(S): This validated method of detection indicates that UPD is extremely rare and suggests that routine screening during preimplantation genetic diagnosis (PGD) may not be necessary. Furthermore, chromosomal UPD is unlikely to explain or support the existence of embryonic self-correction

Three-dimensional ultrasound diagnosis of adenomyosis is not associated with adverse pregnancy outcome following single thawed euploid blastocyst transfer: prospective cohort study.

OBJECTIVES: The objectives of this study were (1) to assess the prevalence of ultrasound (US) features of adenomyosis in an infertile population undergoing in-vitro fertilization (IVF), (2) to define the inter- and intrarater agreement of three-dimensional (3D) US assessment of adenomyosis, and (3) to evaluate sonographic features of adenomyosis with respect to pregnancy outcome following transfer of a single thawed euploid blastocyst. METHODS: This was a prospective cohort study. Subjects scheduled to undergo a single thawed euploid blastocyst transfer between April and December 2017 at a large IVF center were eligible for inclusion. Enrolled subjects underwent endometrial preparation for frozen embryo transfer. 3D-US was performed on the day prior to embryo transfer, with images stored for subsequent evaluation. Subjects then underwent transfer of a single thawed euploid blastocyst, and pregnancy outcomes were collected. All 3D-US volumes were de-identified and reviewed independently by five reproductive endocrinologists/infertility specialists with expertise in gynecological US for the presence of seven sonographic features of adenomyosis: global uterine enlargement, myometrial wall asymmetry, heterogeneous echogenicity, irregular junctional zone, myometrial cysts, fan-shaped shadowing and ill-defined myometrial lesions. Adenomyosis was considered to be present if the majority of the reviewers noted at least one of the seven sonographic features. Inter- and intrarater agreement was evaluated using Fleiss\u27s kappa. Clinical and cycle characteristics of subjects with and those without adenomyosis were compared. The primary outcome of interest was live birth rate. Secondary outcomes included clinical pregnancy rate and miscarriage rate. Logistic regression analysis was performed to account for potential confounders. RESULTS: A total of 648 subjects were included. The prevalence of adenomyosis on US was 15.3% (99/648). On retrospective chart review, very few patients with adenomyosis had symptoms. The inter- and intrarater agreement amongst five independent specialists conducting the 3D-US assessments of adenomyosis were poor (κ = 0.23) and moderate (κ = 0.58), respectively. Subjects with adenomyosis were older (37.1 vs 35.9 years, P = 0.02) and more likely to undergo a gonadotropin-releasing hormone agonist downregulation protocol when compared with those without adenomyosis (12.1% vs 5.1%, P = 0.02). Clinical pregnancy (80.0% vs 75.0%) and live birth (69.5% vs 66.5%) rates were similar between the groups. When adjusting for potential confounders, there was no difference in the rate of clinical pregnancy (adjusted odds ratio (aOR), 1.47 (95% CI, 0.85-2.56)), miscarriage (aOR, 1.3 (95% CI, 0.62-2.72)) or live birth (aOR, 1.28 (95% CI, 0.78-2.08)) between subjects with and those without adenomyosis. No individual sonographic marker of adenomyosis was predictive of pregnancy outcome. CONCLUSIONS: The inter-rater agreement of 3D-US assessment of adenomyosis is poor. Furthermore, sonographic markers of adenomyosis in asymptomatic patients may not be associated with altered pregnancy outcome following transfer of a single thawed euploid blastocyst. These findings suggest that routine screening for asymptomatic adenomyosis in an unselected infertile patient population undergoing frozen embryo transfer may not be warranted. © 2020 International Society of Ultrasound in Obstetrics and Gynecology

Versican Proteolysis by ADAMTS Proteases and Its Influence on Sex Steroid Receptor Expression in Uterine Leiomyoma.

CONTEXT: Leiomyomas have abundant extracellular matrix (ECM), with upregulation of versican, a large proteoglycan. OBJECTIVE: We investigated ADAMTS (a disintegrin-like and metalloprotease with thrombospondin type 1 motifs) protease-mediated versican cleavage in myometrium and leiomyoma and the effect of versican knockdown in leiomyoma cells. DESIGN: We used quantitative reverse transcription polymerase chain reaction (qRT-PCR), western blotting, immunohistochemistry, and RNA in situ hybridization for analysis of myometrium, leiomyoma and immortalized myometrium and leiomyoma cells. Short interfering RNA (siRNA) was used to knockdown versican in leiomyoma cells. SETTING: This study was performed in an academic laboratory. PATIENTS: Study subjects were women with symptomatic or asymptomatic leiomyoma. MAIN OUTCOME MEASURES: We quantified messenger RNAs (mRNAs) for versican splice variants. We identified ADAMTS-cleaved versican in myometrium and leiomyoma and ADAMTS messenger RNAs and examined the effect of VCAN siRNA on smooth muscle differentiation and expression of estrogen and progesterone receptors. RESULTS: The women in the symptomatic group (n = 7) had larger leiomyoma (P = 0.01), heavy menstrual bleeding (P \u3c 0.01), and lower hemoglobin levels (P = 0.02) compared with the asymptomatic group (n = 7), but were similar in age and menopausal status. Versican V0 and V1 isoforms were upregulated in the leiomyomas of symptomatic versus asymptomatic women (P = 0.03 and P = 0.04, respectively). Abundant cleaved versican was detected in leiomyoma and myometrium, as well as in myometrial and leiomyoma cell lines. ADAMTS4 (P = 0.03) and ADAMTS15 (P = 0.04) were upregulated in symptomatic leiomyomas. VCAN siRNA did not effect cell proliferation, apoptosis, or smooth muscle markers, but reduced ESR1 and PR-A expression (P = 0.001 and P = 0.002, respectively). CONCLUSIONS: Versican in myometrium, leiomyomas and in the corresponding immortalized cells is cleaved by ADAMTS proteases. VCAN siRNA suppresses production of estrogen receptor 1 and progesterone receptor-A. These findings have implications for leiomyoma growth