Human Reproduction Update Advance Access originally published online on March 2, 2007
Human Reproduction Update 2007 13(5):421-431; doi:10.1093/humupd/dmm001
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Endometrial bleeding
Abnormal bleeding is a significant health problem, especially during adolescence and before menopause when anovulatory cycles are common. Curettage is rarely necessary to investigate or treat menstrual problems in adolescents, and its use should also be minimized in women younger than 40 years. In every age group, medical treatment is the initial choice, but surgical treatment by endometrial destruction or hysterectomy is sometimes required. Benign causes of bleeding include fibroids and possibly adenomyosis, but the indications for treatment in each case depend upon the extent of bleeding, not the extent of the lesion. Breakthrough bleeding (BTB) with combined oral contraceptives commonly leads to discontinuation of the method. As BTB tends to improve with time, in the first 3 months of pill use, unless there are obvious underlying causes, women should be reassured that it will likely settle. BTB is often the reason for discontinuing progestogen-only contraception, and there is a need for effective means of treating unscheduled bleeding. Bleeding occurs in 
3% of post-menopausal women, and the use of hormones increases the likelihood of bleeding by >5-fold. Knowledge of the underlying mechanisms of bleeding is essential to the development of effective treatment.
Key words: menstruation / endometrial bleeding / heavy menstrual bleeding
1 A meeting was organized by ESHRE (Capri, August 30–31, 2006) with an unrestricted educational grant from Schering S.p.A. to discuss the above subjects. The speakers included: D. Apter (The Sexual Health Clinic, Family Federation of Finland, Helsinki, Finland), D.T. Baird (Centre for Reproductive Biology, University of Edinburgh, UK), J. Collins (McMaster University, Hamilton, Canada), H.O.D. Critchley (Centre for Reproductive Biology, The Queen's Medical Research Institute, Edinburgh), J.L.H. Evers (Deptartment Obstetrics Gynecology Academic Hospital Maastricht, The Netherlands), A. Glasier (Family Planning and WW Services, Edinburgh, UK), P. Vercellini (II Department of Obstetrics and Gynecology, University of Milano, Italy), K. Vogelsong (UNDP/UNFPA/WHO/World Bank Special Programme in Human Reproduction, World Health Organization, Geneva, Switzerland). The discussants included: G. Benagiano (Dipartimento di Scienze Ginecologiche, Università di Roma, Italy), P.G. Crosignani (II Department of Obstetrics and Gynecology, University of Milano, Italy), E. Diczfalusy (Karolinska Institutet, Stockholm, Sweden), C. La Vecchia (Istituto Mario Negri, Milano, Italy), A. Lanzone (Clinica Ostetrica e Ginecologica, Policlinico A. Gemelli, Roma, Italy), S.O. Skouby (Department of Obstetrics and Gynecology, University of Copenhagen, Denmark) and A. Volpe (Dipartimento Integrato Materno Infantile, Università di Modena, Italy). The report was prepared by J. Collins and P.G. Crosignani.
2 Correspondence address: II Department of Obstetrics and Gynecology, University of Milano, Via Commenda 12, 20122 Milano, Italy. E-mail: piergiorgio.crosignani{at}unimi.it
Received on October 31, 2006; revised November 30, 2006; accepted on January 3, 2007