Dysfunctional uterine bleeding in adolescents

Dysfunctional uterine bleeding is a common complaint in adolescent girls. Clinicians working in pediatric, internal medicine, and gynecology offices and in emergency departments are often called upon to make this diagnosis. Dysfunctional bleeding is defined as irregular, painless bleeding of endometrial origin that may be excessive, prolonged, or unpatterned. Although the bleeding is usually secondary to anovulation, the diagnosis is one of exclusion. To make an accurate diagnosis, the clinician must understand the normal adolescent menstrual cycle and related hormone feedback mechanisms. This article reviews the normal hormone mechanisms in the adult and adolescent menstrual cycles in an effort to guide the clinician through the diagnosis. Potential causes and recommended treatment modalities are reviewed.     

Dysfunctional uterine bleeding and dysmenorrhea

OBJECTIVES: To examine the socio-economic effects of team-based clinical case management of patients with chronic minor disease bound for early retirement. DESIGN: Marginal analysis of programme costs and benefits to society compared with no-programme baseline of costs occurring in society due to productivity loss. Prospective patient data collection on admission, discharge, and at one year and five years after discharge to determine programme effectiveness. SETTING: Out-patient clinic at the department of social medicine in tertiary care hospital. SUBJECTS: 239 patients with minor disease and long-term vocational absence consecutively admitted to the study. At the one-year evaluation, 17 patients had been readmitted to the team, 7 could not be found, 6 declined the interview and 2 were deceased. At the five-year evaluation of 49 patients who were active after one year, one was deceased and 10 were unable to be found. MAIN OUTCOME MEASURES: Vocational activity. Programme costs. Benefits to society measured by decrease in indirect costs. RESULTS: The one-year vocational rehabilitation rate from the program was 20.5% and the five-year rehabilitation rate was 11.3%. The total discounted cost for case management of the 239 patients was 7.3 MSEK (600,000 Pounds). The decrease in the indirect costs to society from the 28 patients found active after five years was 35.1 MSEK (2,500,000 Pounds). The net present value of the programme at the 1991 price level was 27.5 MSEK (2,365,000 Pounds). CONCLUSIONS: Tertiary care level team-based clinical case management for vocational rehabilitation of patients with chronic minor disease has a positive cost-benefit ratio. A cross-boundary awareness at a health policy level is needed of the societal costs involved for this group of patients who fall between the traditional services in health care and social work.     

Modern treatments of menorrhagia attributable to dysfunctional uterine bleeding

The adaptive significance of the scrotum and the evolution of the descent of the testicles and epididymis have been a focus of interest among biologists for a long time. In this paper we use three anatomical character states of the scrotum and descensus: (1) testicles descended and scrotal; (2) testicles descended but ascrotal; (3) testicles not descended (testicondy). These states are then mapped on an up to date phylogeny of the Mammalia. Three main points arise out of this mapping procedure: (1) the presence of a scrotum is either primitive in extant Mammalia or primitive within eutherian mammals except Insectivora; (2) evolution has generally proceeded from a scrotal condition to progressively more ascrotal; (3) loss of testicular descensus is less common in mammalian evolution than is loss of the scrotum. In the light of these findings we discuss some current hypotheses regarding the origin and evolution of the scrotum. We find that these are all incomplete in so far as it is not the presence of the scrotum in various mammal groups that requires explaining. Instead, it is the reverse process, why the scrotum has been lost in so many groups, that should be explained. We suggest that the scrotum may have evolved before the origin of mammals, in concert with the evolution of endothermy in the mammalian lineage, and that the scrotum has been lost in many groups because descensus in many respects is a costly process that will be lost in mammal lineages as soon as an alternative solution to the problem of the temperature sensitivity of spermatogenesis is available.     

The decision-making process for the treatment of abnormal uterine bleeding

This pilot study was conducted to investigate the treatment decision-making process of patients and physicians for abnormal uterine bleeding (AUB). Frequently, women with AUB are referred for hysterectomy without diagnostic workup, alternative therapeutic management, or patient input (i.e., patient treatment preferences). Variations in treatment strategies used for patients may be related to a number of factors external to the patient's underlying disease. However, little is known about which factors are most influential or about the extent to which they influence physicians' and patients' decisions. We prospectively followed the management and treatment of 52 women with complaints of AUB and examined differences in treatment among these patients. Extensive previsit interviews were conducted with these women to identify each patient's symptoms, health status, functional status, and preferences for and expectations of treatment. We then conducted telephone interviews within a week of the visit and again 9-12 months later to determine the treatment plan, patient level of participation in and satisfaction with the treatment, symptoms, and functional status. Overall, our findings suggest that patients want to be involved in making treatment decisions and that when women were presented with alternatives to hysterectomy, many chose alternative medical therapy or other surgical procedures. In addition, women reported that these alternative treatments produced significant improvement in symptom intensity and functioning. Increased patient participation in decision making enhanced patient satisfaction. These findings suggest that hysterectomy rates may be decreased by offering women alternative treatments and by finding ways to increase women's participation in their treatment decisions.     

Dysfunctional filtering blebs

Guarded filtration surgery, is commonly used to control the intraocular pressure (IOP) in glaucomatous patients. Filtration surgery lowers the IOP by creating a fistula between the inner compartments of the eye and the subconjunctival space (i.e., filtering bleb). There are several options to improve the function of filtering blebs and to prevent their failure. However, improvement of IOP control after guarded filtration procedures is associated with a higher frequency of bleb-related complications. Early (e.g., bleb leak, excessive filtration, flat anterior chamber, filtration failure) and late (e.g., bleb leak, excessive filtration and hypotony, symptomatic blebs, bleb encapsulation, filtration failure, bleb infection) complications associated with filtering procedures should be managed adequately to prevent further problems. Techniques to improve the function of filtering blebs and to treat postoperative complications have progressed over the past decade.     

Endometrial lymphomyeloid cells in abnormal uterine bleeding due to levonorgestrel (Norplant)

Endometrial lymphomyeloid cell subsets were evaluated in samples from normal women and from women with abnormal uterine bleeding due to subcutaneous levonorgestrel implants (Norplant) or an intrauterine device (IUD). The frequency of CD3(+), CD68(+), CD43(+) and endometrial granulated lymphoid cells was evaluated by immunohistochemical or phloxine-tartrazine staining of formalin-fixed paraffin-embedded samples. In normal women, cyclic variation in lymphomyeloid subsets was seen. In women using Norplant for contraception, the frequency of CD3(+), CD68(+) and CD43(+) cells was dramatically decreased, compatible with endometrial atrophy. When Norplant users with abnormal bleeding were compared to women without bleeding, however, the number of CD68(+) cells was significantly increased and the number of CD3(+) and CD43(+) cells was preserved, contrary to the hypothesis that this group would show a greater degree of atrophy and hence, tissue fragility. A similar pattern was seen in a preliminary study of women with bleeding associated with use of copper-only IUD contraception, and in samples taken from late secretory and menstrual biopsies from normal cycling women. Whether these changes in endometrial lymphomyeloid cells represent a result of bleeding arising from a common mechanism or rather cause the uterine bleeding is discussed.     

A prospective study of transvaginal hydrosonography in the evaluation of abnormal uterine bleeding

OBJECTIVE: To perform a cost-benefit analysis of a Chlamydia trachomatis screening program based on first-void urine testing of asymptomatic women using a polymerase chain reaction (PCR) test. METHODS: A decision tree was developed. Selected variables based on assumptions were subjected to sensitivity analyses to make the model accurate and defensible. RESULTS: Screening for chlamydial infections using the PCR test was shown to be cost-effective even in low-prevalence populations. Compared with a symptom-driven no-screening situation, a universal C trachomatis screening program using the PCR test would save money, in terms of direct cost, when the baseline prevalence of C trachomatis infection exceeds 3.9%. CONCLUSION: Cost analyses are still rare among trials that compare pharmacologic or procedural health care interventions. Socioeconomic studies linking secondary prevention of C trachomatis infection and infertility and adverse pregnancy outcome are needed to convince public health authorities of the need for and the benefit of such programs.     

Comparison of sonography, sonohysterography, and hysteroscopy for evaluation of abnormal uterine bleeding

We compared transvaginal sonography, sonohysterography, and diagnostic hysteroscopy in the evaluation of abnormal uterine bleeding, Sixty-eight women 40 or older with abnormal uterine bleeding were assigned to undergo either transvaginal sonography or sonohysterography. All subjects then had diagnostic hysteroscopy and endometrial biopsy. Patients with abnormal findings underwent operative hysteroscopy or definitive therapy. Transvaginal sonography, sonohysterography, and diagnostic hysteroscopy revealed a sensitivity of 95%, 90%, and 78%, and a specificity of 65%, 83%, and 54%, respectively. The average cost for transvaginal sonography of sonohysterography was $195 and the cost for diagnostic hysteroscopy was $675. Transvaginal sonography and sonohysterography are cost-effective alternatives and more sensitive diagnostic tests than office diagnostic hysteroscopy.     

Office hysteroscopy versus transvaginal ultrasonography in the evaluation of patients with excessive uterine bleeding

Successful treatment of a severe haemoptysis with microcoil embolization in an en block double-lung transplanted patient is described. A 53 year old woman with advanced bronchiolitis obliterans syndrome experienced severe haemoptysis 26 months after an en bloc double-lung transplantation with direct bronchial artery revascularization using the left internal mammary artery. Bronchoscopy showed that the haemoptysis originated from the lingula. Only two months after the transplant, left internal mammary arteriograms revealed proliferation and enlargement of the bronchial arteries in the lingula. The early occurrence of the vascular malformation indicated a pre-existing bronchiectasis in the donor lung, possibly due to tobacco smoking. After uncomplicated microcoil embolization of the left internal mammary artery, the patient experienced no further episodes of haemoptysis. Microcoil embolization can be used successfully to treat massive haemoptysis related to proliferated and enlarged bronchial arteries in transplanted lungs with bronchial artery revascularization.     

Randomised trial comparing hysterectomy with endometrial ablation for dysfunctional uterine bleeding: psychiatric and psychosocial aspects

OBJECTIVE: To compare in psychiatric and psychosocial terms the outcome of hysterectomy and endometrial ablation for the treatment of dysfunctional uterine bleeding. DESIGN: Prospective randomised controlled trial. SETTING--Obstetrics and gynaecology department of a large teaching hospital. SUBJECTS: 204 women with dysfunctional bleeding for whom hysterectomy would have been the preferred treatment were recruited over 24 months and randomly allocated to hysterectomy (99 women) or to hysteroscopic surgery (transcervical resection (52 women) or laser ablation (53 women). MAIN OUTCOME MEASURES: Mental state, martial relationship, psychosocial and sexual adjustment in assessments conducted before the operation and one month, six months, and 12 months later. RESULTS: Both treatments significantly reduced the anxiety and depression present before the operation, and there were no differences in mental health between the groups at 12 months. Hysterectomy did not lead to postoperative psychiatric illness. Sexual interest after the operation did not vary with treatment. Overall, 46 out of 185 (25%) women reported a loss sexual interest and 50 out of 185 (27%) reported increased sexual interest. Marital relationships were unaffected by surgery. Personality and duration of dysfunctional uterine bleeding played no significant part in determining outcome. CONCLUSIONS: Hysteroscopic surgery and hysterectomy have a similar effect on psychiatric and psychosocial outcomes. There is no evidence that hysterectomy leads to postoperative psychiatric illness.     

Dysfunctional attitudes are mood-state dependent.

To test the hypothesis that self-report of dysfunctional attitudes is mood-state dependent, dysfunctional attitudes were assessed in 43 women before and after they received a depressed or elated mood induction. As predicted, the mood induction produced reliable changes in mood and in dysfunctional attitudes, although the increase in dysfunctional attitudes following the negative mood induction was not large enough to be statistically significant. We also tested the hypothesis, from the cognitive theory of depression, that subjects with previous episodes of depression would report more dysfunctional attitudes than would subjects without such a history. As predicted, subjects who reported previous episodes of depression endorsed more dysfunctional attitudes than did subjects who did not report such a history. However, this effect occurred only for subjects who were in a negative mood state when their dysfunctional attitudes were assessed. These findings support the proposition of the cognitive theory that dysfunctional attitudes are traits but suggest that these traits are mood-state dependent. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Dysfunctional disorders of the biliary tract

Gallbladder (GB) and Sphincter of Oddi (SO) dysfunctions represent the dysfunctional disorders of the biliary tract (BTDD) that manifest clinically as a variable combination of chronic or recurrent biliopancreatic symptoms and/or pancreatitis not explained by structural abnormalities. GB and SO dysfunctions are motor disorders of muscle contractility that, irrespective of the potential etiologic factors, cause abnormal GB emptying and, respectively, obstruction to the flow of bile and/or pancreatic juice into the duodenum. GB dysfunction is usually diagnosed on clinical grounds in patients with biliary type pain not accompanied by increase of temperature not by laboratory examinations and in whom ultrasonography (US) and/or cholescintigraphy can possibly detect an altered GB emptying. Although cholecystectomy is the most appropriate treatment of GB dysfunction and 50% to 70% of the patients benefit of cholecystectomy, no single test can predict the long-term outcome of surgery. SO dysfunction is usually suspected in cholecystectomized patients on clinical grounds, laboratory, US, and endoscopic retrograde cholangiopancreatography (ERCP) findings. The diagnosis is supported by the measure of the extrahepatic bile transit time at cholescintigraphy and confirmed by SO manometry. Endoscopic sphincterotomy is the usual treatment of SO dysfunction that has an elevated therapeutic efficacy in patients with manometric diagnosis. Emotional and behavioral factors may play a direct role as precipitants of biliary pain or an indirect role by inducing eating behaviors at risk for BTDD. The possible presence of psychological and/or psychiatric components which may predispose to, coexist with, or manifest in reaction to the BTDD should be taken into consideration when developing a treatment strategy for these patients.     

The reproducibility of the results of transvaginal sonography of the uterus in patients with abnormal uterine bleeding

Our objectives were to determine the reproducibility, or interobserver agreement, of transvaginal sonographic imaging of the uterus in patients with abnormal uterine bleeding and to identify the effect of observer experience. Transvaginal ultrasound findings of 235 patients with abnormal uterine bleeding were recorded systematically on videotape. Recordings were reviewed by three observers who had different levels of experience, and who were asked to judge the endometrium/uterine cavity and myometrium separately as being normal, abnormal or inconclusive, according to predefined criteria. Reproducibility was expressed by the observed rates of interobserver agreement and by kappa statistics. The differences in agreement between observer pairs were analyzed by means of McNemar's chi 2 test. The observed rates of agreement for the judgement of the endometrium/uterine cavity varied from 0.85 to 0.89, with a kappa value ranging from 0.70 to 0.78 between observers. The judgment of the myometrium resulted in agreement rates of 0.86-0.91 and kappa values of 0.67-0.80. Although the effect of experience was evident, the differences in agreement between observers were not significant (p > 0.01). The reproducibility of the results of transvaginal sonography of the uterus in patients with abnormal uterine bleeding was good. Observations of the endometrium/ uterine cavity with a normal appearance were the most highly reproducible, with the smallest effect of observer experience. This may reduce the need for invasive diagnostic procedures in patients with abnormal uterine bleeding.     

Dysfunctional voiding in women: which muscles are responsible?

We studied the effect of mixed agonist-antagonist opioids (nalbuphine and pentazocine) and a kappa opioid agonist (U50488H) on gastric emptying and gastrointestinal transit, and their interactions with morphine in rats. In each group, nalbuphine (0.01-30 mg kg-1), pentazocine (1-30 mg kg-1), U50488H (1-100 mg kg(-1)1) or saline was injected i.p. at 0 min. Another four groups of rats received morphine 13.4 mg kg-1 (ED75) and one of the following substances: saline, nalbuphine, pentazocine or U50488H. In both groups, at 30 min, radiolabelled saline 1 ml was infused into the stomach; at 1 h, gastric emptying and gastrointestinal transit were calculated by measuring the radioactivity in the gastrointestinal tract. Slopes for dose-response curves were determined. Nalbuphine significantly, but only weakly, delayed gastric emptying (P < 0.0005) and gastrointestinal transit (P < 0.01). Pentazocine markedly inhibited both, whereas U50488H did not significantly inhibit either. The slopes of the dose-response curves for nalbuphine, but not for pentazocine, on both gastric emptying and gastrointestinal transit were significantly less steep than those for morphine. Nalbuphine significantly antagonized the inhibitory effect of morphine on gastric emptying (P = 0.005) and gastrointestinal transit (P = 0.02), whereas pentazocine and U50488H did not. Nalbuphine and pentazocine delay gastric emptying and gastrointestinal transit, possibly by different mechanisms.     

How Does Dysfunctional Thinking Decrease During Recovery From Major Depression?

Decreased dysfunctional thinking in recovering depressed patents could reflect predominantly (a) reduced access to dysfunctional schemas or (b) increased metacognitive monitoring of dysfunctional schematic products. Twenty acutely depressed patients, 20 partially remitted depressed patients, and 20 controls were compared on tasks primarily reflecting one or the other of these processes. On both tasks, acutely depressed patients differed significantly from controls. Partially remitted patients resembled acutely depressed patients on the task assessing dysfunctional schema access but resembled controls on the metacognitive monitoring task. Results suggest that reduced dysfunctional thinking associated with partial remission is mediated primarily by increased metacognitive monitoring of dysfunctional cognitive products rather than reduced access to dysfunctional schemas. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Acute gastrointestinal bleeding

Diagnosis and intervention in pediatric GI bleeding is the shared responsibility of pediatric endoscopists, radiologists, and surgeons. Brisk hemorrhage, though alarming, is most often self-limited; few cases require urgent surgery before diagnostic evaluation is accomplished. The choice between endoscopic and radiographic evaluation varies with the differential diagnoses being considered and with local referral patterns. Many imaging options exist for assessing GI bleeding in children, but these options are generally narrowed by clinical history and age-appropriate differential possibilities.