Marlies Y. Bongers

Treatment options for heavy menstrual bleeding depend on the uterine anatomy, the women’s preferences and personal ideas, her age and her future child wish. If the uterus has a normal anatomy, treatment options include hormonal or non-hormonal drugs (including levonorgestrel releasing intra-uterine systems; LNG-IUS), endometrial ablation and hysterectomy. In general, the main advantage of pharmacological treatment is the reversibility and therefore the eligibility for women, independent of age and future child-wish. This article provides a literature review on the effectiveness of medical treatment (hormonal and non-hormonal) for heavy menstrual bleeding and to discuss the dilemmas experienced by women and doctors. A literature search was performed focusing on the effectiveness of hormonal and non-hormonal medical treatment of women suffering from heavy menstrual bleeding. For nonsteroidal anti-inflammatory drugs (NSAIDs) as well as tranexamic acid, direct evidence for comparison to placebo is available, for the other agents (oral progestins (luteal phase and long term); LNG-IUS; combined hormonal contraceptives (combined oral contraceptive pills, combined vaginal ring), evidence could be extracted from a recent network meta-analysis. Evidence on treatment effects on HMB of the progesterone only pill and the etonogestrel subdermal implant is lacking. LNG-IUS appears to be the best pharmacological treatment option for HMB in terms of reducing blood loss as well as improving symptoms. Professionals should be aware that a number of women want to avoid a hormone-containing treatment, this may be due to (expected) negative side effects. In conclusion, considering pharmacological treatment of HMB without underlying pathology, LNG-IUS seems to be the best option to reduce menstrual blood loss. However, it is advised to carefully listen what women want, think and believe and to make a shared tailor-made decision. Pharmacological treatment for HMB should be initiated as a surgical intervention can be avoided. However, women who are not receptive to first-line drug treatments should be given the opportunity to improve their quality of life by getting rid of disabling symptoms of heavy menstrual bleeding, by offering treatment with endometrial ablation or hysterectomy.

Pathogenic TMPRSS6 variants impairing matriptase-2 function result in inappropriately high hepcidin levels relative to body iron status, leading to iron refractory iron deficiency anemia (IRIDA). As diagnosing IRIDA can be challenging due to its genotypical and phenotypical heterogeneity, we assessed the transferrin saturation (TSAT)/hepcidin ratio to distinguish IRIDA from multi-causal iron deficiency anemia (IDA). We included 20 IRIDA patients from a registry for rare inherited iron disorders and then enrolled 39 controls with IDA due to other causes. Plasma hepcidin-25 levels were measured by standardized isotope dilution mass spectrometry. IDA controls had not received iron therapy in the last 3 months and C-reactive protein levels were TMPRSS6-unrelated IDA early in the diagnostic work-up of IDA provided that recent iron therapy and moderate-to-severe inflammation are absent. These observations warrant further exploration in a broader IDA population.

Objective: The aim of this research was to evaluate uterine-wall integrity 12 months after transcervical fibroid ablation (TFA) of uterine fibroids with the Sonata ^® system (Gynesonics Inc., Redwood City, CA). Materials and Methods: INTEGRITY is a secondary analysis of the FAST-EU clinical trial, a prospective, longitudinal, multicenter single-armed trial involving women with heavy menstrual bleeding secondary to fibroids who were treated at 7 academic and community hospitals in the United Kingdom, the Netherlands, and Mexico with transcervical, intrauterine, ultrasound-guided radiofrequency ablation (the Sonata system). TFA was performed on up to 5 fibroids per subject ranging from 1–5 cm in diameter as determined by magnetic resonance imaging (MRI). All measurements and comparisons, including uterine-wall thicknesses were derived from baseline and 12-month MRI scans by an independent core MRI center. Scans were analyzed to assess preservation of uterine-wall integrity and reviewed for uterine-wall anomalies after TFA with the Sonata system. Results: Twenty-nine patients had baseline and 12-month MRI with contrast enhancement. Minimum uterine-wall thicknesses in all visible slices were >2.5 mm in diameter. No areas on MRI indicated any loss of uterine-wall integrity, compared with baseline imaging; comparison of baseline and postablation uterine-wall thicknesses revealed no significant changes. Conclusion: Transcervical fibroid ablation with the Sonata system was associated with preservation of uterine-wall integrity in this patient cohort.