Consulting a Patient on Hormonal Contraception: A Clinical Case of Vulvar Vestibulitis

This article presents a clinical case of a 23-year-old female who developed vulvodynia and dyspareunia while taking combined oral contraceptives (OCs). The case study shows that physicians should not recommend any combination of OCs over another to reduce weight gain, headache, breast tenderness, breakthrough bleeding, sexual dysfunction, dyspareunia, and decreased libido. Hormonal contraception counseling should be based on known, evidence-based recommendations and not be limited to the unnecessary substitution of one drug for another.

British menopause society tools for clinicians: Progestogens and endometrial protection

Progestogen administration is required to oppose naturally produced or administered estrogens to provide endometrial protection. Within HRT regimens, this should be delivered for at least the same duration as that produced during the luteal phase of the monthly cycle and in the recommended doses to protect against the risk of endometrial hyperplasia and endometrial cancer. This includes progestogens administered for 12–14 days a month in sequential regimens and continuous daily intake in continuous combined HRT regimens. Shorter durations and lower doses of progestogen intake are likely to be associated with an increased risk of breakthrough bleeding, endometrial hyperplasia, and endometrial cancer.

Characterizing menstrual bleeding changes occurring after SARS-CoV-2 vaccination

Many people began sharing that they experienced unexpected menstrual bleeding after SARS-CoV-2 inoculation. This emerging phenomenon was undeniable yet understudied. We investigated menstrual bleeding patterns among currently and formerly menstruating people, with a research design based off our expectations that these bleeding changes related to changes in clotting or inflammation, affecting normal menstrual repair. In this sample, 42% of people with regular menstrual cycles bled more heavily than usual, while 44% reported no change, after being vaccinated. Among people who typically do not menstruate, 71% of people on long-acting reversible contraceptives, 39% of people on gender-affirming hormones, and 66% of post-menopausal people reported breakthrough bleeding. We found increased/breakthrough bleeding was significantly associated with age, other vaccine side effects (fever, fatigue), history of pregnancy or birth, and ethnicity. Changes to menstrual bleeding are not uncommon nor dangerous, yet attention to these experiences is necessary to build trust in medicine.

Thrombosis and novel hemophilia therapies: the fine line between clotting and bleeding

The availability of novel nonfactor therapeutics is revolutionizing the management of hemophilia in individuals with inhibitory antibodies, as well as making prophylaxis more convenient even in the absence of inhibitors. Unfortunately, the use of these products has been associated with thrombotic events that are not typically seen with factor replacement. These are primarily seen when a patient on a nonfactor therapy experiences breakthrough bleeding and concomitantly receives another hemostatic agent. This video addresses thrombotic complication in 3 nonfactor products: (1) emicizumab, a bispecific antibody that mimics the cofactor activity of factor VIII; (2) fitusiran, an small interfering RNA that knocks down synthesis of antithrombin; and (3) concizumab, an antibody that blocks inhibition of factor Xa by tissue factor pathway inhibitor. The latter 2 agents were developed on the premise that hemostasis in hemophilia could be “rebalanced” by reducing the levels of anticoagulant activity to compensate for the defect in procoagulant activity. Each of these approaches increases peak levels of thrombin achieved in assays on plasma from treated subjects and reduces bleeding rates in individuals with or without inhibitors. However, we do not yet have a good mechanistic model for precisely how these approaches affect hemostasis in vivo. It is not only the total amount of active thrombin produced that determines the effectiveness of hemostasis but also how thrombin generation is regulated. Therefore, it is currently difficult to predict how these new agents will interact with other perturbations or therapeutic manipulations of the coagulation system.

Real-World Data on Bleeding Patterns of Hemophilia A Patients Treated with Emicizumab

Emicizumab (Hemlibra™) is approved for prophylaxis of hemophilia A (HA) patients. The HAVEN studies addressed bleeding reduction in emicizumab-treated patients, but real-world data on bleeding patterns during emicizumab therapy are lacking. We aimed to compare the occurrence of breakthrough bleeding at different time points, starting from emicizumab initiation. This longitudinal prospective observational cohort study included HA patients (n = 70, aged 1 month to 74.9 years) that completed at least 18 months of follow-up in our center. We analyzed the number of spontaneous and traumatic bleeds during selected time points of the study (“bleeding periods”). The percentage of traumatic and spontaneous bleeding episodes was not significantly different among “bleeding periods” (P = 0.053 and P = 0.092, respectively). Most trauma-related treated bleeds resulted from either hemarthrosis (53%) or head trauma (33%). Spontaneous bleeding episodes were mostly hemarthroses (80%). Potential associations of the patients’ age, annualized bleeding rate before emicizumab treatment, and the presence of inhibitors with spontaneous bleed occurrence were analyzed with binomial logistic regression. The odds of bleeding while on emicizumab increased by a factor of 1.029 (P = 0.034) for every one year of age. Conclusions: Our real-world data revealed that the risk of bleeding persists, especially in older patients, despite therapy with emicizumab. These data may help clinicians in counselling their patients and in planning their management.

Menarche in primary ovarian insufficiency after a month of hormone replacement therapy: a case report

Background Gynecologic anomalies, including uterine agenesis and ovarian dysgenesis, are some of the several differential diagnoses in adolescent females with primary amenorrhea and delayed puberty. Primary ovarian insufficiency is reported in the clinical practice of reproductive endocrinology can be determined by conducting sex hormone tests to evaluate the hypothalamic-pituitary-ovarian axis. However, confirmation of Mullerian agenesis by image modalities can be extremely challenging. Once the diagnosis is established, breakthrough bleeding usually occurs 2 to 3 years after hormonal replacement therapy. Case presentation We report a case of a seventeen year old Taiwanese female, 46 XX karyotype, with ovarian dysgenesis and an initial tentative diagnosis of uterine agenesis who experienced a breakthrough bleeding after a month of hormonal replacement therapy. Conclusions The breakthrough bleeding after a month of estrogen therapy in primary ovarian insufficiency is uncommon, and the diagnosis of the absent uterus can have an extensive psychological impact on patients and their families.

Management of bleeding in women on HRT

Bleeding while on hormone replacement therapy is common. Debby Holloway explains the causes of this, investigations needed, and how to tailor treatment to the individual if no pathology is found Bleeding while taking hormone replacement therapy (HRT) is a relatively common problem. The majority of women with post-menopausal bleeding – on and off HRT – will have either no cause or a benign cause, but about 10% of women will have endometrial cancer. Post-menopausal bleeding is defined as unscheduled vaginal bleeding that occurs a year after the last natural menstrual period or any breakthrough bleeding on cyclical HRT or breakthrough bleeding after 6 months on continuous combined therapy when there has been established amenorrhoea. Practice nurses must be aware of the problem of bleeding on HRT and each individual needs to be assessed for pathology. If no pathology is found, treatment should be tailored to the individual to overcome the bleeding issues.