25/06/2018 Definition • Heavy menstrual bleeding (HMB) is defined as excessive menstrual blood loss which interferes with a woman's physical, social, emotional and/or material quality of life. Heavy Menstrual Bleeding (HMB): Replaced ‘menorrhagia’ Objective definition of HMB >80mL/ cycle or duration of >7 days Causes and Management • It can occur alone or in combination with other symptoms (e.g. intermenstrual bleeding, pelvic pain, pressure symptoms) Dr. William (Wee-Liak) Hoo, MD MRCOG Consultant Gynaecologist Prevalence King’s College Hospital NHS FT • The prevalence of HMB in objective studies (9 to 14%) and subjective studies 20 to 52%) in studies based on subjective assessment. • In the UK, almost 1.5 million women consult their General Practitioners UKCPA Women’s Health Group Masterclass (GPs) each year with menstrual complaints and the annual treatment cost Friday 22nd June 2018 exceeds £65 million. Causes • Uterine: Uterine fibroids (dysmenorrhoea, palpable mass, pressure symptoms) Adenomyosis (dysmenorrhoea, subfertility) Endometrial polyps (intermenstrual bleeding) Pelvic inflammatory disease (PID)/ infection (vaginal discharge, pelvic pain, intermenstrual and postcoital bleeding and pyrexia) Malignancy or atypical hyperplasia (irregular/ postcoital/ intermenstrual bleeding, pelvic pain, weight loss). • Ovarian: Polycystic ovary syndrome (acne, hursuitism) • Systemic diseases: Hypothyroidism (fatigue, constipation, cold intolerance and hair and skin changes) Coagulation disorders (e.g. von Willebrand disease) Liver or renal disease • Iatrogenic Anticoagulant treatment (warfarin, heparin) Copper Intrauterine Devices (IUD) Herbal supplements (e.g. ginseng, ginkgo and soya) — alters oestrogen levels or coagulation parameters Assessment • Taking a detailed clinical history. nature of the bleeding, impact on the woman's quality of life, Other factors which may affect treatment options (fertility, comorbidities, previous treatments?) IMB, PCB, pressure symptoms Previous treatments • Physical examination General & abdominal examination Pelvic and speculum examination +/- swabs (for infection) • Investigation: Full blood count for all women with HMB. Additional tests where appropriate e.g. coagulation screening, thyroid function testing. Ultrasound assessment – transvaginal +/- abdominal Outpatient Hysteroscopy Consider endometrial biopsy for women: Age >45 Persistent intermenstrual or irregular bleeding Infrequent heavy bleeding who are obese or have polycystic ovary UTERINE FIBROIDS syndrome Previous unsuccessful treatment (LEIOMYOMAS) 1 25/06/2018 ADENOMYOSIS • Definition - a benign condition of the uterus defined by the presence of endometrial glands and stroma within the myometrium. • Until recently, diagnosis was histological (post hysterectomy) = difficulties in assessing prevalence and clinical significance lack of clear and uniform histological criteria • Transvaginal ultrasound (TVS) and magnetic resonance • Fibroid growth is variable (vs. linear) - 18 to 120% per year imaging (MRI) shown to have high levels of accuracy in the pre-operative diagnosis of adenomyosis. • Fibroids undergo spontaneous regression, growth and shrinkage spurts outside of TVS well tolerated, inexpensive and widely available menopause • Overall prevalence of adenomyosis was 20.9% • Factors that influences growth rates: Increased with age, peaks at 32% in 40–49yo. Fibroid size at presentation - no agreement as to whether smaller or larger fibroids grew faster. • Women with ultrasound features of adenomyosis was Submucous fibroids were least likely to increase in size significantly more likely to have severe menstrual pain A reduction in growth rates with increasing age – only in black women • The endometrial–myometrial junction (EMJ) is thought to play an important role in both physiological and pathophysiological processes within the uterus. High resolution ultrasound assessment equipment with three- dimensional (3D) imaging facilities is often required • Ultrasound features of adenomyosis include: Management [NG88] asymmetrical myometrial thickening, • Consider starting pharmacological treatment for HMB without myometrial cysts, investigating the cause if the woman's history and/or examination suggests a low risk of fibroids, uterine cavity abnormality, histological linear striations, abnormality or adenomyosis. parallel shadowing, adenomyomas, • In women with no identified pathology, fibroids <3 cm or hyperechoic islands adenomyosis an irregular EMJ on B-mode or 3D imaging Pharmacological Treatments LNG-IUS(first treatment) non-hormonal: tranexamic acid NSAIDs hormonal combined hormonal contraception cyclical oral progestogens progesterone only contraception Surgical Option 2nd generation endometrial ablation Trancervical resection for submucous fibroids Hysterectomy 2 25/06/2018 Management Pharmacological • Levonorgestrel-releasing intrauterine system (LNG IUS) • In women fibroids >3 cm LNG released at 20 mg/ day – exerting local effects (thinning and atrophy of endometrium) Esmya (Ullipristal acetate) Reduces menstrual loss by up to 95% after 1 year, full benefit may not be seen in the first 6 months – temporary safety measure! Very little systemic absorption of the hormone Anyone on Esmya - monthly liver function testing SE: breast tenderness, headache, acne, erratic bleeding (esp. first 6 months) Do not start any new courses of Esmya, even if it was used safely • Tranexamic Acid: before. Antifibrinolytic, reducing menstrual blood loss by 58% Uterine artery embolization SE: indigestion, diarrhoea or headache (rare) CI: history of venous or arterial thromboembolism, renal impairment Surgical (including pre-treatment with a gonadotrophin- Cochrane review – more effective than NSAIDS, lutueal phase progesterone and placebo releasing hormone analogue) Myomectomy • Non-steroidal anti-inflammatory drugs (NSAIDs): Prostaglandin synthetase inhibitors Hysterectomy Mefenamic acid most frequently used, reduces blood loss by approximately 25%. SE: inhibits ovulation, indigestion, diarrhoea, aggravates asthma and peptic ulcer disease. Cochrane review – more effective than placebo but less than tranexamic or LNG IUS. • Combined oral contraceptive pill Reduction of menstrual loss of 43%. SE: nausea, mood changes, breast tenderness and VTE (esp. smokers, ↑BMI and ↑ age). • Progestogens Cyclical - Norethisterone acetate (5 mg, TDS – taken from day 5 to 26) reduces HMB SE: weight gain, bloating, breast tenderness, headache, acne and depression. Endometrial Ablation Uterine Artery Embolization • Endometrial ablation is targeted destruction of endometrium. • Procedure • Second generation techniques fluid filled • Interventional Radiology (IR) – LA/ sedation thermal balloon ablation and impedance • MRI assessment controlled endometrial ablation. • Percutaneous catheter Day cases • Embolisation of uterine arteries Pre ablation endometrial histology should be • Collaterals – ovarian and vaginal arteries obtained Advised to use effective contraception • Advantages • Shorter waiting times • Ideally: • No general anesthesia Uterus no bigger than 10 weeks pregnancy size • Shorter recovery Smaller fibroids <3cm • Lower total cost Family must be complete • Disadvantages / Side-Effects • Post operatively: • Post-embolization syndrome transient crampy abdominal pain and • Serious complications – sepsis watery brown discharge (3 - 4 weeks) • Fertility – Miscarriage rate, POI • 20% re-intervention rate • Outcome 1/3 amenorrhoeic, 1/3 markedly reduced menstrual loss and 1/3 no difference Hysteroscopic Resection Myomectomy - Surgical Approach FIGO stage Approach Comments L 0-1 Hysteroscopic Fluid overload L 2-8 Laparoscopic or Selection criteria for Open Laparoscopic Uterine size Number of fibroids Total volume of fibroids Number of uterine incision Multiple Combined or Open surgery • GnRH agonist – 3 months before surgery • Risks: bleeding, transfusion, infection, hysterectomy 3 25/06/2018 FDA Safety Alerts (2014, 2017) Fibroid Uterus Cavity Questions? 4.