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Abnormal uterine bleeding (AUB) is a common side effect of hormonal contraceptive (HC) use and represents a significant cause of treatment discontinuation. Two main types of bleeding are recognized: withdrawal bleeding, which occurs during the hormone-free interval following a sudden drop in hormone levels, and breakthrough bleeding (BTB), defined as unscheduled bleeding during active hormone administration. Combined oral contraceptives (COCs) may induce BTB due to hormonal fluctuations or insufficient endometrial stabilization, while progestin-only contraception (POC) is commonly associated with abnormal bleeding due to endometrial changes induced by continuous progestin exposure. A structured and clinically oriented framework for the management of AUB in the context of HC is presented, highlighting the importance of appropriate counseling. Some strategies to improve adherence have been proposed, recognizing non-compliance as a major contributor to unscheduled bleeding. Contraceptive choice is addressed as an individualized process, involving adjustments to hormone type and dosage based on woman-specific needs. The aim is to provide clinicians with a clear and structured tool to address a highly prevalent yet often overlooked issue, still marked by significant uncertainty and inconsistency in the current literature.

Abnormal uterine bleeding (AUB) is a common problem for which women seek gynecological consultation. Endometrial aspiration cytology (EAC) is an acceptable and valuable diagnostic procedure for screening the endometrial status. Endometrial aspiration using a menstrual regulation (MR) syringe and a 4 mm Karman's cannula was performed just prior to D and C in 100 women presenting with AUB. Smears were reviewed for cytomorphological findings and were correlated with the histopathological findings. These findings were categorized as benign endometrium, endometrial hyperplasia, malignancy and inadequate smears. Age of the patients ranged from 19 to 70 years. In our study, the accuracy in diagnosing benign conditions of endometrium, hyperplasia, and malignancy on aspiration cytology were 93.88%, 96.94% and 96.84%, respectively. Endometrial aspiration is an effective, useful and a minimally invasive procedure. With an experienced cytologist, it can be used routinely for the primary investigation of women with AUB, provided all the points of discrepancies are taken care of.

Dysmenorrhea is a common symptom secondary to various gynecological disorders, but it is also represented in most women as a primary form of disease. Pain associated with dysmenorrhea is caused by hypersecretion of prostaglandins and an increased uterine contractility. The primary dysmenorrhea is quite frequent in young women and remains with a good prognosis, even though it is associated with low quality of life. The secondary forms of dysmenorrhea are associated with endometriosis and adenomyosis and may represent the key symptom. The diagnosis is suspected on the basis of the clinical history and the physical examination and can be confirmed by ultrasound, which is very useful to exclude some secondary causes of dysmenorrhea, such as endometriosis and adenomyosis. The treatment options include non-steroidal anti-inflammatory drugs alone or combined with oral contraceptives or progestins.

Uterine fibroids are the most common benign tumors in women, with abnormal uterine bleeding (AUB) as the main reported symptom. Additionally, an association between fibroids and infertility has been established, especially if the fibroid protrudes in the uterine cavity. Hormonal therapy is associated with side-effects and as well as hysterectomy, which is incompatible with a desire to conceive. To improve treatment, it is essential to unravel the etiology of fibroid-related symptoms. We aim to evaluate endometrial angiogenesis in women with fibroids, with and without AUB, and the influence of pharmaceutical therapies in these patients. Furthermore, we explore the possible role of altered angiogenesis in patients with fibroids and infertility. We performed a systematic review according to PRISMA-guidelines (PROSPERO: CRD42020169061), and included 15 eligible studies. Endometrial expression of vascular endothelial growth factor (VEGF) and adrenomedullin was increased in patients with fibroids. This suggests aberrant angiogenesis, potentially involving disturbed vessel maturation, resulting in immature and fragile vessels. Treatment with gonadotropin-releasing hormone agonist, ulipristal acetate, and continuous oral contraception pills reduced several angiogenic parameters, including VEGF. If infertile and fertile patients with fibroids were compared, a significant decreased expression of the bone morphogenetic protein/Smad-protein pathway was found, possibly caused by the increased expression of transforming growth factor-beta. For future therapeutic development, these different angiogenic pathways could be of interest as possible targets to treat fibroid-related symptoms.

We investigated menstrual irregularities after the first and second doses of the COVID-19 vaccine. Women answered a customised online questionnaire (ClinicalTrial.gov ID: NCT05083065) aimed to assess the vaccine type, the phase of the menstrual cycle during which the vaccine was administered, the occurrence of menstrual irregularities after the first and second doses, and how long this effect lasted. We excluded women with gynaecological and non-gynaecological diseases, undergoing hormonal and non-hormonal treatments, in perimenopause or menopause, as well as those who had irregular menstrual cycles in the last 12 months before vaccine administration. According to our data analysis, approximately 50–60% of reproductive-age women who received the first dose of the COVID-19 vaccine reported menstrual cycle irregularities, regardless of the type of administered vaccine. The occurrence of menstrual irregularities seems to be slightly higher (60–70%) after the second dose. Menstrual irregularities after both the first and second doses of the vaccine were found to self-resolve in approximately half the cases within two months. Based on these results, we suggest to consider these elements during the counselling of women who receive the COVID-19 vaccine, letting them know about the potential occurrence of temporary and self-limiting menstrual cycle irregularities in the subsequent month(s).

Abnormal uterine bleeding (AUB) represents a notable sign for benign and malignant uterine pathology. Differentiating adenomyosis from leiomyoma via hysteroscopy aids in selecting appropriate surgical or medical management. Accurate diagnosis is crucial for optimizing fertility outcomes and symptom control. The current study evaluated the diagnostic accuracy of hysteroscopy in differentiating between uterine adenomyosis and leiomymatosis. In addition to; compare between continuous versus intermittent administration of Norethissterone to control both uterine adenomyosis and leiomymatosis. A total of 100 premenopausal women present with AUB. History takin and clinical evaluation was done. All women were subjected to hysteroscopy. Two regimens were used by Norethindrone administration the 1st regimen as continuous manner from day 5 to day 21 46 patients (46%). The 2nd manner was the intermittent type from day 16 and for 10 days 54 patients (54%). Roc-curve of hysteroscopy usage to predict diagnosis; adenomyosis sensitivity was 73.33% and specificity 95.29% and fibroid sensitivity was 73.33% and specificity was 97.65%. Both groups of therapy revealed; highly significant decrease in follow up menorrhagia in continuous Norethindrone group ( P  < 0.001).By using ROC-curve analysis; Norethindrone administration predicted decreased menorrhagia pain with AUC was 0.973. Hysteroscopy has effective role in differentiating between adenomyosis and fibroids. Yet, long term follows up of abnormal uterine bleeding cases with large sample size in future research are still warranted.

To evaluate if a preoperative medical treatment with the GnRH-antagonist relugolix in combination therapy in a series of patients with abnormal uterine bleeding associated with uterine myomas may correct the anemia before scheduled surgery for myoma-associated AUB. Thirty-one patients scheduled for surgery underwent a pre-operative three-month course with a daily oral tablet of 40 mg relugolix, 1 mg estradiol, and 0.5 mg norethindrone acetate. Hemoglobin levels, uterine volumes, largest myoma diameter, and VAS score for dysmenorrhea, pelvic pressure and bleeding discomfort, and indication to surgery were evaluated at study enrollment and at the end of therapy. Mean hemoglobin levels increased by 25%, from 9.3 ± 1.1 to 11.6 ± 1.7 g/dL after three months ( p  < 0.001). Uterine volume decreased from 380.7 ± 273.4 mL to 281.7 ± 198.7 mL ( p  < 0.001), whereas the diameter of the largest myoma decreased from 6.4 ± 2.8 cm to 5.5 ± 2.2 cm ( p  < 0.001). Four patients (13%), initially planned for a laparotomy procedure, were converted to a minimally-access procedure, whereas in eight patients (26%) surgery was avoided after medical therapy. Dysmenorrhea score improved from 4.7 ± 3.2 to 0.6 ± 1.1 ( p  < 0.0001). Pelvic pressure score decreased from 5.9 ± 2.1 to 3.1 ± 2.3 ( p  < 0.0001), whereas bleeding discomfort decreased from 7.4 ± 3.0 to 0.4 ± 1.6 ( p  < 0.0001). Preoperative GnRH-antagonist therapy may enhance hemoglobin levels, decrease uterine and myoma size, and alleviate symptoms, potentially enabling safe surgical procedures.

Adenomyosis is a benign uterine disorder in which endometrial glands and stroma are pathologically demonstrated in the uterine myometrium and it is considered a specific entity in the PALM-COEIN FIGO (polyp; adenomyosis; leiomyoma; malignancy and hyperplasia; coagulopathy; ovulatory dysfunction; endometrial; iatrogenic; and not yet classified - International Federation of Gynecology and Obstetrics) classification of causes of abnormal uterine bleeding (AUB). Although it has always been considered the classic condition of multiparous women over 40 years old who have pain and heavy menstrual bleeding, diagnosed at hysterectomy, the epidemiological scenario has completely changed. Adenomyosis is increasingly identified in young women with pain, AUB, infertility, or no symptoms by using imaging techniques such as transvaginal ultrasound and magnetic resonance. However, there is no agreement on the definition and classification of adenomyotic lesions from both the histopathology and the imaging point of view, and the diagnosis remains difficult and unclear. A uniform and shared reporting system needs to be implemented in order to improve our understanding on imaging features, their relationship with pathogenic theories, and their importance in terms of clinical symptoms and response to treatment. In fact, adenomyosis pathogenesis remains elusive and not a single theory can explain all of the different phenotypes of the disease. Furthermore, adenomyosis often coexists with other gynecological conditions, such as endometriosis and uterine fibroids, increasing the heterogeneity of available data. Treatment requires a lifelong management plan as the disease has a negative impact on quality of life in terms of menstrual symptoms, fertility, and pregnancy outcome and has a high risk of miscarriage and obstetric complications.

Background Pictorial blood loss assessment charts (PBACs) represent the most widely used method to assess menstrual blood loss (MBL) in clinical trials. The aims of this review were to: (1) determine the diagnostic accuracy of PBACs that have been validated against the reference alkaline hematin technique; (2) categorize the pitfalls of using obsolete and nonvalidated charts; (3) provide guidelines for development of a new PBAC or use of an existing chart to measure MBL in clinical trials; and (4) consider the feasibility of using pictorial charts in primary care. Methods A literature review was conducted using Embase and MEDLINE databases. The review identified reports of women with self-perceived or actual heavy menstrual bleeding (HMB), bleeding disorders, abnormal uterine bleeding, leiomyomata (uterine fibroids) or endometriosis, and women undergoing treatment for HMB, as well as those with normal menstrual periods. Data were reviewed from studies that focused on the development and validation of PBACs and from those that used derivative noncertified charts to assess HMB. Results Nine studies reported validation of PBAC scoring systems against the alkaline hematin technique. Across these studies, the sensitivity was 58–97%, the specificity was 7.5–95.5%, the positive and negative likelihood ratios were 1.1–13.8 and 0.14–0.56, respectively, and the diagnostic odds ratio was 2.6–52.4. The cut-off score above which the diagnosis of HMB was made ranged from 50 to 185. Several modifications of these PBACs were used in other studies; however, objective confirmation of their validity was not reported. Overall, there was widespread inconsistency of chart design, scoring systems, diagnostic cut-off limits and post-treatment outcome measures. Conclusions PBACs are best suited to the controlled and specific environment of clinical studies, where clinical outcome parameters are defined. The current lack of standardization precludes widespread use of the PBAC in primary care. Review registration number PROSPERO international prospective register of systematic reviews: CRD42016030083.

The rapid deployment of COVID-19 vaccines has necessitated the ongoing surveillance of adverse events, with abnormal uterine bleeding (AUB) emerging as a reported concern in vaccinated females. We aimed to develop a machine learning (ML) model to predict post-vaccination AUB in women aged less than 50 years. A large-scale national cohort, the Korean Nationwide Cohort (K-COV-N cohort), was utilized, comprising over 7 million participants. The study employed advanced ML techniques, including ensemble models combining gradient boosting machine and logistic regression, and conducted feature importance analysis. The dataset was meticulously curated, focusing on relevant demographics and variables, and balanced using Synthetic Minority Over-sampling Technique. Using a national cohort of over 2 million COVID-19 vaccinated cases in South Korea, we developed a ML model for AUB prediction. Our study is the first to develop a predictive model for post-vaccination AUB, employing feature importance analysis to identify the key contributing factors. The analysis revealed three primary predictive features: COVID-19 vaccination frequency, NVX-CoV2373 (Novavax) COVID-19 vaccination count, and hemoglobin levels. These findings provide valuable insights into predicting the risk AUB following COVID-19 vaccination, potentially enhancing post-vaccination monitoring strategies.