Direct Hysteroscopic Observation to Document the Reasons for Abnormal Bleeding Secondary to Submucous Myoma

Baggish, Michael S.; Sze, Eddie H.M.; Rosenzweig, Bruce A.; Birenbaum, Debra L.; Refai, Ashraf M.N.

doi:10.1089/gyn.1989.5.149

Cited by 14 publications

(7 citation statements)

References 9 publications

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“…1,4,5 Increased intramural pressure can lead to blocked venous drainage and EMVE, which is the likely cause of bleeding in fibroid uteri. 1,8 Our working hypothesis is that these dilated endometrial vessels, which can be visible on hysteroscopy and associated with endometrial ecchymoses, 22 do not rupture and bleed until they thrombose-due to the combined effects of blocked venous drainage and Virchow's Triad. 1 However, modern pathology textbooks do not cite this literature, 8,22 and many pathologists may be unaware of the symptomatic effects of EMVE.…”

Section: Discussionmentioning

confidence: 99%

“…1,8 Our working hypothesis is that these dilated endometrial vessels, which can be visible on hysteroscopy and associated with endometrial ecchymoses, 22 do not rupture and bleed until they thrombose-due to the combined effects of blocked venous drainage and Virchow's Triad. 1 However, modern pathology textbooks do not cite this literature, 8,22 and many pathologists may be unaware of the symptomatic effects of EMVE. It is suggested that EMVE may be "the lesion for which surgery was performed" (Figure 3A and B) in the current group of 32 hysterectomies for bleeding-since reports of proliferative, secretory, deciduoid, or inactive endometrium do not explain abnormal bleeding.…”

Section: Discussionmentioning

confidence: 99%

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A Comparison of Hysterectomies for Bleeding With Hysterectomies for Pain

2019

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Objectives. We recently suggested that increased intramural pressure may often explain pain and/or bleeding. Hysterectomies for bleeding tend to have outward bulges and endometrial vascular ectasia, while hysterectomies for pain tend to have deflection of pressure inward by subserosal ridges, which promote inner myometrial elastosis (IME). Study design. We analyzed causes of increased intramural pressure in 58 hysterectomies for pain and/or bleeding, excluding clinically fibroid uteri and prolapsed uteri. Postfixation photographs were used to avoid missing grossly obvious myometrial hyperplasia (MMH). Results. The most common cause of increased intramural pressure was grossly obvious MMH in 40/58 cases (69%). Other causes included clinically occult myomas (3 cases), adenomyosis (6 cases), and multifactorial causes (7 cases). Hysterectomies for bleeding weighed more than hysterectomies for pain ( P = .035). Hysterectomies for pain had more IME than hysterectomies for bleeding ( P = .029). Conclusions. When subserosal ridges deflect pressure inward, bulky MMH may cause pelvic pain and IME, but when they do not, bulkier MMH in heavier uteri may lead to both outward bulges and abnormal bleeding from endometrial vascular ectasia.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

A Comparison of Hysterectomies for Bleeding With Hysterectomies for Pain

2019

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“…Even more important, and equally unfamiliar to most pathologists, these dilated fragile endometrial vessels were seen by Baggish et al in 1989 to rupture spontaneously during hysteroscopy in uteri with submucous fibroids, leaving behind endometrial ecchymoses. 42 This explanation for abnormal bleeding was generated in the era when "an underperforming big idea had become entrenched," that is, "unnecessary hysterectomy." 1,4 It provided a plausible long-sought explanation for what Silverberg described in 1977 as dysfunctional uterine bleeding.…”

Section: Increased Intramural Pressurementioning

confidence: 99%

A Review and Reconsideration of Nonneoplastic Myometrial Pathology

Cramer

Heller²

2017

Int J Surg Pathol

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From 1861 to 1962, clinicopathologic research tried to explain the association of abnormal uterine bleeding with uterine enlargement. The etiology was theorized as metropathy, suggesting that myometrial dysfunction may predispose to abnormal uterine bleeding. Research reached a nadir in 1962, when a major review dismissed myometrial hypertrophy as a plausible explanation after prior rejections of the theories of chronic myometritis, fibrosis uteri, and subinvolution as causes of bleeding. Subsequent to this arose a crusade against unnecessary hysterectomies in the 1970s. Although myometrial hyperplasia was proposed in 1868, it is only in the past 25 years that tangible evidence has supported that idea. It now appears that clinically enlarged uteri are due to globoid outward bulging of the uterus, caused by increased intramural pressure-often unrelated to either uterine weight or myometrial thickness. Abnormal (dysfunctional) uterine bleeding may often be due to spontaneous rupture of thrombosed dilated endometrial vessels, due to the combined effects of obstructed venous drainage by increased intramural pressure, and Virchow's triad. Despite a century-old known association of parity with naturally occurring outer wall myometrial scars (fibrosis uteri with elastosis), it was not previously suggested that these may reflect healing reactions to muscle tears during labor and delivery. We now suggest that smaller, similar inner wall elastotic scars in the nerve-rich inner myometrium may explain many cases of pelvic pain. This review suggests that diverse pressure-related lesions may be present in clinically abnormal uteri that have been called "normal" since the crusade against unnecessary hysterectomy.

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“…Several hypotheses have been proposed to explain menorrhagia associated with uterine myomata. According to the hysteroscopic observations of Baggish and colleagues 5 , excessive bleeding in the presence of submucous fibroids is due to the tendency to spontaneous rupture of large, thin‐walled surface veins that cover the tumours. Bleeding from these distended vessels is liable to be prolonged and profuse due to the absence of surrounding contracting myometrium, which would exert a mechanical haemostatic effect.…”

Section: Causes Of Leiomyomata‐associated Menorrhagiamentioning

confidence: 99%