Britt Friberg

Bleeding disorders among young women: A population-based prevalence study

Background. Bleeding problems are prevalent in the general population but may indicate a general bleeding disorder. Our aim was to describe the prevalence of perceived bleeding symptoms, including menorrhagia, in young healthy females. Methods. By aid of school nurses we distributed a questionnaire to all girls (n=1,410) in the first grade of the upper secondary schools in the town of Malmö, Sweden. We received 1,019 (72%) responses. The questionnaire consisted of 17 main questions addressing general bleeding problems, menses and menstrual bleeding problems, family history, and other health related questions. Results. The mean age of the girls was 16.7 years. Eight girls had a previously diagnosed bleeding disorder and had a higher frequency of most bleeding symptoms. Seventy‐three percent of girls experienced at least one bleeding symptom, 43% had more than one symptom, 23% were troubled by more than two symptoms, and 10% more than three symptoms. Thirty‐seven percent experienced heavy menstruation and of these 22% had different drugs as treatment for menorrhagia. Thirty‐eight percent had a family history of heavy menstruation and half of them suffered from heavy menstruation themselves. Conclusions. Bleeding symptoms were relatively prevalent in this population and similar to other population‐based studies.

Distribution of von Willebrand factor levels in young women with and without bleeding symptoms : influence of ABO blood group and promoter haplotypes

The normal distribution of von Willebrand factor (VWF) levels is wide. Low levels are associated with bleeding symptoms and von Willebrand disease (VWD). We have recently described a high prevalence of bleeding symptoms in a whole age group of young females (n = 1,019) from Malmo, Sweden. It was the objective of the present study to evaluate the distribution of VWF levels in young females with or without bleeding symptoms in this population, and the influence of ABO blood group and promoter haplotypes on VWF levels and to identify a possible increased prevalence of VWD in females with bleeding symptoms. A random selection of the female age group (n = 246), into a study group (n = 176) with, and a control group (n = 70) without bleeding symptoms, was evaluated. Eighteen girls had VWF:RCo below the reference range, of which 17 belonged to the study group (17/176, 9.7%), and one to the control group (1/70, 1.4%) (p = 0.017). Blood group O was found in 14/18 girls with low VWF:RCo. There was a highly significant correlation between VWF:RCo and blood group O and non-O genotypes. Two common VWF promoter haplotypes did not contribute to the VWF:RCo variation. VWF levels did not correlate with time during menstrual cycle, or the use of oral contraceptives. No case fulfilled the diagnostic criteria for VWD. In conclusion, low VWF:RCo was significantly more frequent in females with bleeding symptoms. However, we found no case fulfilling strict diagnostic criteria for VWD. The ABO blood group was a strong modifier, but VWF promoter haplotypes had no association to VWF levels in this population.

Endometrial Thermal Coagulation – Degree of Uterine Fibrosis Predicts Treatment Outcome

Objective: To study the uterine cavity after thermal endometrial destruction for the treatment of menorrhagia by means of a balloon catheter, the CavatermTM system. To relate the appearance of the uterine cavity to the outcome of the treatment. Methods: Fifty-one of the first 60 women treated with balloon endometrial destruction were examined with hysteroscopy and saline infusion sonography 11–28 months after treatment. Results: Patients with minimal or no bleeding after thermal endometrial destruction had more uterine fibrosis than patients bleeding more. Conclusion: The greater the degree of fibrosis of the uterine cavity after balloon endometrial destruction by thermal coagulation, the better the effect on menorrhagia.

Tubal patency studied by ultrasonography: A pilot study

Transvaginal hysterosalpingoultrasonography (HSUG) was performed using a uterine cannula and Ringers solution (Kabi Baxter) as a contrast agent in 14 women consulting for infertility. The results were compared with those of chromopertubation at laparoscopy/ laparotomy. With HSUG, the uterine cavity was always well visualized, though it was more difficult to evaluate tubal status. As compared with those of the other methods, HSUG findings manifested total agreement in 50% of cases, total disagreement in 22%, and partial agreement in the remaining 28%. The method was well tolerated by the women studied, and six out of nine women who had previously undergone hysterosalpingography (HSG) found HSUG to cause less discomfort. Thus, the findings suggest that HSUG might prove useful as a means of ascertaining tubal status at an early stage in infertility evaluations.

Thermal conductivity of uterine tissue in vitro

Thermotherapy of the uterus has emerged as an alternative to hysterectomy in the treatment of menorrhagia, from whence it follows that the thermal properties of uterine tissue have become of importance. This study presents measurements of the thermal conductivity and the water content of uterine tissue in vitro. A steady-state thermal conductivity apparatus, based on the comparison of test samples with a material with known thermal conductivity, is described. Measurements were conducted on tissue samples from eleven patients, directly after hysterectomy. Samples with and without endometrium, as well as coagulated samples, were examined. The thermal conductivity of myometrial tissue was found to be 0.536 +/- 0.012 W m(-1) K(-1) (mean +/- 1 SD) and the corresponding water content was 81.2 +/- 1.5% (mean +/- 1 SD). Measurements on samples with both endometrium and myometrium showed similar thermal conductivity (0.542 +/- 0.008 W m(-1) K(-1), mean +/- 1 SD) and water content (81.6 +/- 0.7%, mean +/- 1 SD). It was also indicated that coagulation causes dehydration, resulting in a lower thermal conductivity.

Deliveries after malignant disease before pregnancy: Maternal characteristics, pregnancy, and delivery complications

PURPOSE Survival after cancer has increased, and the question of risks in later pregnancies has become important. A previous malignancy may affect pregnancy outcome. METHODS Comparison of women with malignant disease before pregnancy with all other women giving birth during 1994-2011. Data were obtained by linkage between Swedish national health registers. Subfertility, evaluated as time to pregnancy, and in vitro fertilization (IVF) before the relevant delivery were studied. The following delivery diagnoses were studied: gestational diabetes, preeclampsia, placenta previa, placenta abruption, placenta retention, bleeding around delivery, and premature rupture of membranes. The rates of cesarean section and vacuum extraction or forceps delivery were also studied. RESULTS We identified 3931 women with 7176 deliveries and with a malignancy diagnosed at least 1 year before the delivery. The total number of deliveries in Sweden in these years was 1,746,870. Overall, an increased risk of subfertility (odds ratio [OR] 1.17, 95% confidence interval [CI] 1.07-1.28), use of IVF (OR = 1.36, CI 1.21-1.53), delivery complications (OR = 1.17, 95% CI 1.10-1.24), and rate of caesarean sections (OR = 1.27, 95% CI 1.20-1.34) was observed among women with a history of malignancy compared with other women. CONCLUSION We found an increased risk of subfertility, pregnancy, and delivery complications in women with a history of malignant disease. Further studies are needed to evaluate the risks of specific treatments and to provide these women with reliable information that could affect their family planning.

Impact of diet and bariatric surgery on anti-Müllerian hormone levels

STUDY QUESTION Do serum levels of anti-Müllerian hormone (AMH) change in women of reproductive age following dietary and surgery-induced weight loss? SUMMARY ANSWER AMH levels increased after very low-calorie diet (VLCD) before surgery and decreased at 6 and 12 months after Roux-en-Y gastric bypass (RYGB), beyond expected normal age-related decline. WHAT IS KNOWN ALREADY Obesity has negative effects on fertility and IVF outcomes, and possibly also on AMH levels. AMH correlates to the number of growing follicles and is used to predict the response to IVF treatment. However, AMH might decrease after bariatric surgery. STUDY DESIGN, SIZE, DURATION A prospective cohort study of 48 women followed first for 8 weeks preoperatively, then operated with RYGB and followed postoperatively for 1 additional year. PARTICIPANTS/MATERIALS, SETTING, METHODS Women aged 18-35 years with a mean (SD) BMI 40.9 (3.6) kg/m2 were included at baseline (BL). After the VLCD, a RYGB was performed. Body weight and height were measured at BL and 1 year postoperatively. Hormones were analysed at BL, after VLCD on the day before surgery, and at 6 and 12 months postoperatively. MAIN RESULTS AND THE ROLE OF CHANCE Median AMH levels were 30.0 pmol/L at BL and rose significantly after VLCD (median: 35.0 pmol/L; P = 0.014). Median AMH at 6 and 12 months postoperatively were significantly lower (19.5 and 18.0 pmol/L, respectively; P = 0.001). Free androgen index (FAI) was significantly lower after 12 months, compared to BL (1.2 vs 3.5, P < 0.0005). LIMITATIONS REASONS FOR CAUTION Ultrasound for PCOS diagnosis was not performed. The change in laboratory methods for AMH analysis during the study might be a limitation. WIDER IMPLICATIONS OF THE FINDINGS Obese young women might choose bariatric surgery also for fertility reasons, and the observed decrease in FAI is in line with improved fertility. More research is needed to evaluate the clinical effects of the decrease of AMH, and the effect of bariatric surgery prior to IVF treatment. STUDY FUNDING/COMPETING INTEREST(S) Study-specific laboratory analyses were funded by the Swedish Regional Research Fund (ALF). Authors declare no competing interests. TRIAL REGISTRATION NUMBER N/A.

Congenital malformations in offspring of women with a history of malignancy

BACKGROUND Survival after malignancy has increased and the question of risks, including risk for congenital malformations for the offspring of these women has become important. Data on congenital malformations in such offspring are limited. METHODS We compared congenital malformation in offspring, born 1994 to 2011 of women with a history of malignancy (at least 1 year before delivery) with all other offspring. Adjustment for confounders was mainly made by Mantel-Haenszel methodology. Data were obtained by linkage between Swedish national health registers. RESULTS We identified 71,954 (4.1%) infants with congenital malformation, of which 47,081 (2.7%) were relatively severe (roughly corresponding to major malformation). Among 7284 infants to women with a history of malignancy 204 relatively severe malformations were found (2.8%; odds ratio [OR] = 1.04; 95% confidence interval [CI], 0.91-1.20). After in vitro fertilization, the risk of a relatively severe malformation was significantly increased in women without a history of malignancy (OR = 1.31; 95% CI, 1.24-1.38) and still more in women with such a history (risk ratio = 1.85; 95% CI, 1.08-2.97). However, there were no significant differences neither, for any malformations (OR = 1.04; 95% CI, 0.92-1.16) nor for relatively severe malformations (OR = 1.04; 95% CI, 0.91-1.20), when comparing offspring only after maternal history of malignancy. CONCLUSION No general increase in malformation rate was found in infants born to women with a history of malignancy. A previously known increased risk after in vitro fertilization was verified and it is possible that this risk is further augmented among infants born of women with a history of malignancy. Birth Defects Research 109:224-233, 2017.

Prematurity and neonatal outcome including congenital malformations after maternal malignancy within six months prior to or during pregnancy

The proportion of women who postpone childbearing is increasing. As malignancy risk increases with age, pregnancy in connection with malignancy will become more common.

Modeling intracavitary heating of the uterus by means of a balloon catheter

Balloon thermal endometrial destruction (TED) is a recently developed method to treat heavy menstrual bleeding (menorrhagia). Numerical simulations of this treatment by use of the finite element method were performed. The mechanical deformation and the resulting stress distribution when a balloon catheter is expanded within the uterine cavity was estimated from structural analysis. Thermal analysis was then performed to estimate the depth of tissue coagulation (temperature > 55 degree(s)C) in the uterus during TED. The estimated depth of coagulation, after 30 min heating with an intracavity temperature of 75 degree(s)C, was approximately 9 mm when blood flow was disregarded. With uniform normal blood flow, the depth of coagulation decreased to 3 - 4 mm. Simulations with varying intracavity temperatures and blood flow rates showed that both parameters should be of major importance to the depth of coagulation. The influence of blood flow was less when the pressure due to the balloon was also considered (5 - 6 mm coagulation depth with normal blood flow).