Abnormal uterine bleeding: The well-known and the hidden face - 05/04/24

Doi : 10.1016/j.jeud.2024.100071 
Caio R.V. Leal a, Silvia Vannuccini b, Varsha Jain c, Marie-Madeleine Dolmans d, e, Attilio Di Spiezio Sardo f, Ayman Al-Hendy g, Fernando M. Reis a, , 1
a Department of Obstetrics and Gynecology, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil 
b Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy 
c MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK 
d Pôle de Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium 
e Gynecology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium 
f Department of Public Health, University Federico II of Naples, Italy 
g Department of Obstetrics and Gynecology, University of Chicago, Chicago, IL, USA 

Corresponding author at: Department of Obstetrics and Gynecology, Division of Human Reproduction, Universidade Federal de Minas Gerais, Av. Alfredo Balena 110 – 9° andar, 310130-100 Belo Horizonte (MG), Brazil. Tel. (55-31) 3307-9485; Fax. (55-31) 3307-9299.Department of Obstetrics and GynecologyDivision of Human ReproductionUniversidade Federal de Minas GeraisAv. Alfredo Balena 110 – 9° andarBelo Horizonte (MG)310130-100Brazil

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Highlights

Menstruation involves interactions between the endocrine and immune systems.
Several interconnected processes are necessary to stop menstrual bleeding.
The pathophysiology of AUB due to structural conditions is poorly known.
Transvaginal ultrasound is the primary diagnostic method for structural causes.
The effectiveness and the long-term actions of AUB therapies need more research.

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Abstract

Abnormal uterine bleeding (AUB) is a bleeding from the uterine corpus that is abnormal in regularity, volume, frequency or duration. It encompasses heavy menstrual bleeding, irregular menstrual bleeding and intermenstrual bleeding, which are common symptoms among women of reproductive age, impacting their overall well-being. Menstruation involves interactions between endometrial epithelial and stromal cells, immune cell influx, and changes in endometrial vasculature. These events resemble an inflammatory response with increased vessel permeability, tissue breakdown, and the arrival of innate immune cells. However, the mechanisms of menstrual cessation are poorly understood. AUB can be related to structural causes (polyp, adenomyosis, leiomyoma, malignancy/hyperplasia) and nonstructural conditions (coagulopathy, ovulatory dysfunction, endometrial, iatrogenic). While transvaginal ultrasound is the primary method for the screening of intracavitary lesions, saline infusion sonohysterography is more accurate to detect endometrial polyps and submucous leiomyomas, while hysteroscopy with biopsy remains the reference method for a definitive diagnosis. The main goals in managing AUB are addressing and correcting the underlying primary cause, if possible, and establishing a regular bleeding pattern or amenorrhea, which can be done with antifibrinolytic agents, progestins, gonadotropin-releasing hormone agonists and antagonists, or surgical interventions, each one with specific indications and limitations. Further research is necessary to assess the effectiveness and the long-term effects of various medical and surgical treatments. Meanwhile, the availability of diagnostic methods such as transvaginal ultrasound and hysteroscopy and the universal distribution of medical treatments for AUB should be prioritized by policymakers to minimize the diagnostic and treatment delay and thus reduce the risk of AUB-related anemia and the need of hysterectomy.

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Keywords : Abnormal uterine bleeding, Heavy menstrual bleeding, Leiomyoma, Adenomyosis, Menstruation


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