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PubMed2002

Cost analysis model: US versus endometrial biopsy in evaluation of peri- and postmenopausal abnormal vaginal bleeding.

PURPOSE: To develop a cost minimization analysis model from the societal perspective of Medicare reimbursement to determine whether endometrial biopsy or transvaginal ultrasonography (US) is less expensive in evaluating peri- and postmenopausal women with abnormal vaginal bleeding and to assess whether this strategy is equally effective in populations at low and high risk for endometrial carcinoma. MATERIALS AND METHODS: Clinical algorithms were constructed that detailed diagnostic evaluation of the target population by using office-based endometrial biopsy versus transvaginal US as starting points. An economic model based on Medicare reimbursement and average wholesale drug price data and using disease prevalences and modality sensitivities from the scientific literature was then created to examine common bleeding causes in this population. All models included the cost of obtaining a tissue diagnosis for focal or diffuse endometrial thickening found at US. Modality sensitivities and prevalences of disease states were varied within the model to discover limits at which each modality became cheaper versus the other for assessing a population of women. RESULTS: Population prevalence of neoplastic disease is the principal factor governing total cost between competing diagnostic algorithms. In populations with 31% or less combined prevalence of endometrial carcinoma/atypical adenomatous hyperplasia, algorithms utilizing transvaginal US as the initial test are most cost minimizing. At combined endometrial carcinoma/atypical adenomatous hyperplasia prevalence of 10%, savings of up to 11% and 16% over pathways initiated with endometrial biopsy are predicted. In populations with a high incidence of neoplastic disease (>31%), biopsy-based algorithms should become least costly. CONCLUSION: Transvaginal US-initiated triage predicts substantial cost savings versus biopsy-based algorithms in evaluating typical populations of peri- and postmenopausal women with abnormal vaginal bleeding seen in clinical practice.

Biopsy, Needle↗
PubMed1988

The management of the patient with abnormal vaginal cytology following hysterectomy.

Thirty-two patients presenting with abnormal vaginal cytology following hysterectomy were studied. Seven (21.8%) had had hysterectomy for benign conditions whilst 25 (78.1%) had cervical intraepithelial neoplasia (CIN) or invasive cervical carcinoma. Twenty-five patients had partial or total vaginectomy (15 as the primary procedure), and one required laser treatment following vaginectomy. Of 11 (34.3%) patients treated primarily by laser, five subsequently required vaginectomy because of persistent or recurrent cytological abnormality. All four patients treated with topical 5-fluorouracil or dinitrochlorobenzene subsequently required surgery. Nine of the 32 patients (28.1%) proved to have invasive carcinoma of the vagina on histological examination of the vaginectomy specimen. At the time of writing all patients in the study are well with no evidence of disease.

Adult↗
PubMed2004

Abnormal vaginal discharge: what does and does not work in treating underlying causes.

Antifungal medications for intravaginal use have been available in the United States for more than a decade. Women may be inclined to self-diagnose yeast infections with any vaginal discharge or other vulvovaginal symptoms that they deem abnormal. As we saw in the first part of this article, "Abnormal vaginal discharge: Using office diagnostic testing more effectively" (J Fam Pract 2004; 53[10]:805-814), abnormal discharge is more likely to be bacterial vaginosis or no pathogen at all. Potential delay in diagnosis and treatment of a sexually transmitted disease is also a concern. Increasing resistance of Candida sp. to imidazoles is associated with indiscriminate use of over-the-counter products.

Anti-Bacterial Agents↗
PubMed1995

Predicting endometrial cancer among older women who present with abnormal vaginal bleeding.

We studied 203 women ages 49 or over who presented with abnormal vaginal bleeding and who underwent either endometrial biopsy or dilation and curettage at the Brigham and Women's Hospital. Using information from the clinical history, we predicted their risk for endometrial cancer (36 patients) or complex endometrial hyperplasia (16 patients). Factors independently associated with endometrial cancer/complex hyperplasia included age 70 or older (OR = 9.1, P = 0.0001), diabetes (OR = 3.7, P = 0.02), and nulliparity (OR = 2.7, P = 0.02). After adjusting for age, menopause was borderline significant (OR = 2.6, P = 0.07). Our data estimated a risk of endometrial cancer/complex hyperplasia of 87% for a woman possessing all of these factors, and a risk of less than 3% if she had none of them. Our model provides an inexpensive, simple means for assessing the risk of endometrial cancer and complex hyperplasia in the post- or perimenopausal woman with abnormal bleeding.

Age Factors↗
PubMed2003

Abnormal vaginal bleeding in the nonpregnant patient.

Vaginal bleeding is a common complaint in most emergency departments. Abnormal vaginal bleeding causes many patients a great deal of stress and inconvenience. Although treatment of most cases is straightforward, vaginal bleeding can herald serious occult disease including cancer, coagulopathy, and systemic illness. Vaginal bleeding can also be the initial complaint in patients suffering sexual abuse or trauma. From an emergency medicine perspective, vaginal bleeding should be approached in terms of whether the patient is stable or not. Subsequent evaluation should exclude or treat problems that might cause the patient's condition to deteriorate. The emergency physician is able to provide initial therapy for most causes of vaginal bleeding, and in most cases the patient must be referred to a gynecologist for further evaluation and treatment.

Adolescent↗
PubMed2004

Abnormal vaginal cytology in HIV-infected and at-risk women after hysterectomy.

OBJECTIVE: To determine the frequency of and risk factors for abnormal vaginal Papanicolaou smears in HIV-infected women after hysterectomy. METHODS: Data were from the HIV Epidemiology Research (HER) study, a prospective multisite study of HIV-infected and uninfected women. Semiannual vaginal Papanicolaou smears and colposcopy data were obtained from 102 HIV-infected and 46 at-risk women who had hysterectomy either before or during the study. Analytic models used include Cox proportional hazards (women with hysterectomy during the study) and multiple logistic regressions, which corrected for repeated measures (all women). RESULTS: Among the HIV-infected women, evidence of cervical intraepithelial neoplasia before or at hysterectomy was associated with abnormal cytology during follow-up; 63% had squamous intraepithelial lesions (SIL) on vaginal Papanicolaou smears following hysterectomy. CD4 counts of <200 cells/microL at hysterectomy and HIV viral load of >10,000 copies/mL at hysterectomy were predictive of SIL vaginal cytology. Prevalent SIL vaginal cytology was associated with low CD4 count and human papillomavirus risk type. Of the 102 HIV-infected women, 16 (16%) had vaginal intraepithelial neoplasia on biopsy. CONCLUSIONS: The high rate of SIL on vaginal Papanicolaou smears and the presence of high-grade vaginal intraepithelial neoplasia among HIV-infected women after hysterectomy demonstrate the need for continued follow-up for lower genital tract lesions.

Adult↗
PubMed1984

[Endometrial curettage in abnormal vaginal bleedings in 1964 and 1983 at the Panti Rapih Hospital, Yogyakarta, and family planning].

This study was undertaken to compare the causes of abnormal vaginal bleedings in 1964 before the family planning program in Indonesia was introduced and in 1983 when this program was widely accepted. The samples were taken from the files of the Department of Pathology, Gadjah Mada University Medical Faculty, during the period of July 1-December 31 in the years 1964 and 1983. The results suggested that in 1964 these bleedings were mainly caused by conception (52.9%), while in 1983 only 19.7% were caused by conception. In 1964 most dysfunctional bleedings were found in the perimenopause groups and in 1983 in the child bearing groups. Extended studies utilizing larger samples could provide further information about the role of estrogen hormones for contraception and therapy or hormones for cosmetic purposes, and also about endogenic factors. It would be necessary to work together with other specialists as well as psychologists.

Asia↗
PubMed1998

Rapid and inexpensive approaches to managing abnormal vaginal discharge or lower abdominal pain: an evaluation in women attending gynaecology and family planning clinics in Peru.

OBJECTIVES: To assess low abdominal pain, yellow vaginal discharge, other symptoms and signs, and demographic and behavioural variables as predictors for cervical or vaginal infection. METHODS: A cross sectional study of women attending gynaecology and family planning clinics in Lima, Peru was undertaken. 630 consecutive eligible female patients with chief or elicited complaints of yellow vaginal discharge, low abdominal pain, or both were interviewed and examined, together with a comparable reference group without these complaints. Vaginal specimens were tested for trichomoniasis and bacterial vaginosis. Endocervical specimens were tested for Neisseria gonorrhoeae and Chlamydia trachomatis using the ligase chain reaction. RESULTS: Infections found included chlamydial infection in 69 women (10.9%), gonorrhoea in 10 (1.6%), and either infection in 77 (12.2%); trichomoniasis in 46 (7.3%), bacterial vaginosis in 189 (30%), and either infection in 209 (33.2%). Cervical infection with C trachomatis and/or N gonorrhoeae was independently associated with history of a new sex partner within the last 3 months, more than one sex partner within the last year, use of condoms never or in less than 50% of sex acts, history of sex partner with STD within the last year; with symptoms of persistent low abdominal pain and of yellow vaginal discharge; and with signs of profuse and yellow vaginal discharge, cervical ectopy, easily induced endocervical bleeding, or brown cervical secretion. Using these findings, an algorithm was created that had a positive predictive value (PPV) of 36% for cervical infection among women reporting chief or elicited complaint of this abnormal vaginal discharge and a PPV of 25% among those without a complaint. A chief complaint of yellow vaginal discharge had a PPV of 50% for trichomoniasis or bacterial vaginosis. Among women without a chief complaint of yellow vaginal discharge, clinical findings of yellow vaginal discharge had a PPV of 55%. CONCLUSIONS: Where economic and technical constraints preclude testing, clinical findings and risk assessment are helpful in detecting vaginal and cervical infections. Several demographic, behavioural, clinical, and laboratory variables were predictive of infection in this population.

Abdominal Pain↗
PubMed1978

The possible role of hemidesmosomes in neonatally estrogen-induced selection of a permanently altered abnormal vaginal epithelium.

In untreated and neonatally-estrogenized (E) Balb/c mice the numbers of hemidesmosomes per basal cell cross section (HD/bccs) gradually increases from 0.07 HD/bccs on day 1 to about 2 to 3 HD/bccs on day 4 postpartum. In untreated mice the incidence of HD's increases and plateaus at 6 to 7 HD/bccs on days 5 and 8, while during this same period in E-treated mice the incidence is increased to 14 to 15 HD/bccs. In 5-day-old E-treated mice two types of basal vaginal epithelial cells can be recognized: basophilic cells rich in HD (19.5 +/- 2.1 HD/bccs) and light cells containing only 5.3 +/- 3.3 HD/bccs. The basophilic, HD-rich cells appear to replace the lighter HD-poor cells. The hypothesis that HD's are involved in the estradiol-induced selection of an abnormal vaginal epithelium is discussed.

Animals↗
PubMed2006

Oral clindamycin and histologic chorioamnionitis in women with abnormal vaginal flora.

OBJECTIVE: Oral clindamycin reduced late miscarriage and preterm birth in asymptomatic women with bacterial vaginosis or intermediate flora. We investigated whether clindamycin reduced the incidence of histologic chorioamnionitis as a mechanism for these beneficial effects. METHODS: This was a subanalysis of 126 participants from a larger randomized controlled trial. We compared the incidence of histologic chorioamnionitis between the clindamycin and placebo groups. Histologic chorioamnionitis was diagnosed by the presence of polymorphonuclear leukocytes, separately in the amnion and chorion, decidua, fetal surface of the placenta, the walls of fetal chorionic vessels, umbilical cord, or in the subchorionic fibrin layer. Microbiologic cultures were done on swabs from the space between the chorion and amnion layers. RESULTS: Histopathologic results were available for 122 placentas, 62 (51%) and 60 (49%) in the clindamycin and placebo groups, respectively. There were no significant differences in inflammation between the groups in the decidua (41% compared with 43%), membranes (25% compared with 41%), fetal vessels (16% compared with 14%), or subchorionic fibrin (32% compared with 34%). Adjusting for gestational age, ethnic origin, or history of miscarriage did not alter the results. There were no significant differences in the outcomes of pregnancy between women with and without inflammation, either before or after adjustment for treatment group. CONCLUSION: Although oral clindamycin reduced late miscarriage and preterm birth in women with abnormal vaginal flora, this effect is unlikely to be mediated through a reduction in the incidence of histologic chorioamnionitis. The relatively small size of the groups, however, does not allow us to rule out a real effect, especially given the lower rate of membrane inflammation observed in the clindamycin group. LEVEL OF EVIDENCE: I.

Abortion, Spontaneous↗
PubMed1999

Cesarean section scar as a cause of abnormal vaginal bleeding: diagnosis by sonohysterography.

A previously undescribed cause of abnormal uterine bleeding is presented. Nine of 310 women evaluated by sonohysterography for abnormal bleeding demonstrated an 8 to 17 mm gap in the anterior lower uterine segment myometrium at the site of prior cesarean deliveries. All women were premenopausal and had a history of 2 to 12 days of postmenstrual spotting. Presumably a lack of coordinated muscular contractions occurs around the cesarean scar, allowing the defect to collect menstrual debris. Subsequently, the debris leaches out through the cervix for several days after the majority of menstrual flow has ceased.

Adult↗
PubMed1997

Evaluation of abnormal vaginal bleeding in perimenopausal women with endovaginal ultrasound and saline infusion sonohysterography.

Saline infusion sonohysterography enhances endovaginal ultrasound examination of the uterine cavity in perimenopausal patients with abnormal uterine bleeding. It is easily and rapidly performed at minimal cost, is extremely well tolerated by patients, and is virtually devoid of complications. Its use can prevent invasive diagnostic procedures in some patients as well as optimize the preoperative triage process for those patients who will require therapeutic intervention.

Female↗
PubMed1996

Outpatient Hysteroscopy in the Management of Abnormal Vaginal Bleeding

We performed outpatient hysteroscopy with endometrial biopsy in approximately 1000 women under local anesthesia. A definitive management plan was made at the single appointment. The combined results were analyzed by age, symptoms, findings at hysteroscopy, and pathology. Ninety percent of women had abnormal bleeding, 50% of whom had a normal hysteroscopy. Patient acceptability was evaluated by questionnaire. Over 90% of women found the procedure acceptable, with minimal discomfort. The failure rate was approximately 5%. Less than 30% of women required a second surgical procedure. Outpatient hysteroscopy is a safe, effective, and well tolerated alternative to dilatation and curettage under general anesthesia, and has the possibility of a definitive diagnosis and management plan at the patient's first visit. It has clear savings, not only in outpatient and inpatient costs, but also in operating room time.

Journal Article↗
PubMed1999

Abnormal vaginal bleeding in adolescence as the presenting symptom of a bleeding diathesis.

Menorrhagia in adolescents may be the presenting sign of a systemic hemostatic disorder. The evaluation of adolescents with menorrhagia should include an assessment of the pelvic organs to exclude anatomic pathology, and if none is found the possibility of primary hematological abnormality should be considered. Initially, a thorough personal and family history of a bleeding tendency should be obtained. Thereafter, we suggest a number of basic "screening" clotting assays be performed. These should include a platelet count, prothrombin time, activated partial thromboplastin time, fibrinogen level and bleeding time. Abnormalities of any of these tests should then be further investigated using more specific clotting assays. The most common disorders reported to cause menorrhagia in adolescents are von Willebrand's disease, factor XI deficiency, and Glanzmann's thrombasthenia. General and specific therapeutic measures for treating these disorders are discussed.

Adolescent↗
PubMed1997

Abnormal vaginal bleeding from endometrial polyps in a woman receiving tamoxifen therapy for breast cancer: report of a case.

We report herein the case of a women receiving tamoxifen therapy for breast cancer who developed vaginal bleeding, subsequently found to be caused by unusual endometrial polyps. Upon presentation, ultrasonography and magnetic resonance imaging (MRI) demonstrated a tumor within the uterus. A hysterectomy was performed, and macroscopic examination showed polyp-like lesions of the uterus. Histologically, these polyps demonstrated cystically dilated glands and stromal proliferation, and were diagnosed as endometrial polyps. Although tamoxifen has few side effects, any signs or symptoms of gynecological abnormalities should be carefully evaluated in patients on long-term tamoxifen therapy.

Antineoplastic Agents, Hormonal↗