Abnormal Uterine Bleeding

Emma ReadmanGynaecologist, EndosurgeonEndosurgery Unit, MHW.Gynaecologist in Charge, Ambulatory Hysteroscopy, MHW

Abnormal Uterine Bleeding: More

Heavier than normal bleeding Prolonged uterine bleeding >10days Frequency < than 3 weeks Intermenstrual spotting or bleeding Post coital bleeding

Increased bleeding: pathogenesis Structural Vs Functional Structural –EXCLUDE PREGNANCY

IUDs Polyps Fibroids

bleeding by endometrial surface area30% to 70% women have fibroids, bleeding caused by those situated near or adjacent to

endometrium, or that otherwise expand endometrial surface area Otherwise often ASYMPTOMATIC,COEXISTANT

Endometrial cancer Endometrial hyperplasia

Menstrual cycle

Functional bleeding Functional: Ovulatory Vs Anovulatory

Ovulatory• loss of local endometrial haemostasis• Progesterone withdrawal mediated spiral

artery vasoconstriction, modulated by prostaglandins (PG), decreased ratio therefore vasodilates

Menorrhagia: Pathogenesis

PGs also opposed by nitrous oxide Other proteolytic enzymes

Anovulatory Bleeding: Systemic in nature: hypothalamo-

pituitary-ovarian axis Also local haemostatic mechanisms

rendered deficient

Menorrhagia: Pathogenesis Also bleeding disorders:Von

Willebrande’s Disease 10.7% in women with menorrhagia(US centres disease control and prevention)

Enhanced fibrinolysis

Clinical evaluation

Abnorm al b leeding

tria l o ftran exam ic ac id

N S A ID (esp if p a in )+ /- O C P

R eg u la r h eavyN U S , p ap , F B E

L H , F S H , TF Tsp ro lac tin , sen s tes t,

F A I, sh b gif lon g te rm , m ay n eed cu re tte

Irreg u la r h eavy

re fe rsp ec ia lis t

P C B /IM B /P M Bab N o f p ap , U S

exam in eU S , p ap , F B E

Medical Options Fe therapy Antifibrinolytics Cyclo-oxygenase inhibitors Progestins Continuous/cyclic Local Inplantable Oestrogens plus progestins Androgens GNRH agonists and antagonists

Antifibrinolytics

Tranexamic acid 1g QID first 4 days cycle for ovulatory DUB

Virtually all cases bleeding reduces 40-60%

Placebo controlled trials show no incr GIT Ses (Cochrane review)

No evidence incr risk thromboembolic disease even if high risk (Lindoff ’93)

Cyclo-oxygenase inhibitors (NSAIDS) Unclear exactly how work but likely generally

reduce PGs locally, therefore vasoconstrict 5/7 trials Cochrane showed mean menstrual

blood loss decreased c/w placebo, 2/7 no change.

Trials usually used mefanamic acid(Ponstan) 250-500mg 2-4x daily, also naproxen and ibuprofen

Randomised trials comparing danazol & tranexamic acid to NSAIDS show both superior

Progestins: cyclic 10/7

Most of world literature uses norethisterone >= 50% with anovulatory DUB get regulated

cycles with cyclical norethisterone, 10 days per month (luteal phase prog)

Women with ovulatory DUB unlikely benefit, may get worse

Cochrane says less effective than tranexamic acid, danazol, Mirena in ovulatory DUB if used 10/7

using tranexamic acid better for general health, IMB and social and sexual functioning (c/w luteal phase prog)

Progestins: cyclic (long cycle) and continuous

Norethisterone 5mg TDS days 5-26 reduced menstrual vol by 87%

Only 22% were willing to continue therapy beyond 3/12, preferred IUD.

Continuous progesterone no published data with DUB

Progestins:Local Mirena, 20mcg levonorgestrel daily 5 ys Greatest impact on bleeding volume of any

med treatment if ovulatory (94% decr blood vol at 3/12, 76% of women wanted to continue post 3/12) Not clear if anovulatory

IUD c/w hysteroscopic endometrial ablation by experts showed 79% decr Vs 89% at 12/12, equivalent satisfaction

Scandinavian open trial with ovulatory DUB scheduled for hysterectomy, 64.3% elected to cancel op c/w 14.3% allocated to current med mx

Progestins: Implantable Implanon (etonogestrel,3rd gen prog) 3 ys Less bleeding, variable pattern 30-40% cycles amenorrhoeic (c/w 51%

Depo) 30% infrequent bleeding (c/w 16% Depo) 10-20% frequent or prolonged bleeding

(c/w 35%) Usually know within 3/12 what pattern will

be but stabilises at 12/12

OCPs

Generally considered effective in Mx of both ovulatory and anovulatory

However, few available data to support 1 RCT demonstrated 50% reduced

flow(small sample size) 1 RCT compared triphasic OPC & placebo

anovulatory DUB 50% “much improved” vs 20%, with better life table scores

Nuvaring

GnRH and Danazol

Danazol >200mg daily, 50% individuals experience decrease menstrual vol,more effective than Ponstan

Ses mean usually not use GNRH plus addback useful ovulatory and

anovulatory, not licensed for this use Australia

Surgery

Hysteroscopic endometrial ablation Laser not common usage-slow,

costly, training issues Electrical loop resection Vs ablation Non-hysteroscopic endometrial

ablation

Endometrial Ablation

Factors that effect outcome of HER/ablation

Better success women>45 Surgeon experience Adenomyosis worse outcome In experienced hands, success rates

larger uteri may be equiv to smaller uteri

Nonhysteroscopic endometrial ablation

Radiofrequency electrosurgical: Vestablate Novasure

Local hyperthermia: Cavaterm HydroThermAblator Thermachoice

Cryotherapy Microwave

Novasure

Randomised trials comparing HER/ablation & hysterectomy 90% success, equal amenorhoea to

hypomenorrhoea (multiple studies) If retreat failures, 50% success Cochrane shows greater patient

satisfaction with hysterectomy Shorter hospital stays, fewer complications,

less cost and earlier return to normal in HEA

Reoperation rates in HEA increase steadily with time, only 1 trial 4 year follow up-40% reoperation rates

Alternative therapies garlic Panax ginseng Chaste tree Wild yam Cramp bark Helionas root

Alternative therapies Garlic

Inhibits platelet aggregation in a dose dependent fashion

Increased fibrinolysis Discontinue use 7 days prior to surgery Advise against use if low platelets

Ginseng Many different ginsenosides different effects Steroidal saponins Lower post prandial glucose May irreversibly inhibit platelet aggregation Stop ginseng 1 week prior to surgery

Case One

Mrs MM, a 24 year old has always had heavy periods, sexually active

Tried OCP, no success 30 and 50 mcg,

Wants children in the next few years

Case two Mrs CC is a 43 year old, had 3

children LUSCS Periods becoming increasingly heavy

over last four years, now flooding, dysmenorrhoea

Needs contraception too

Case three Ms PV is a 45 year old Heavy irregular periods increasing

over last 2 years Some hot flushes