Heavy menstrual bleeding NICE Guidelines, Aboubakr Elnashar

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Heavy menstrual bleeding NICE Guidelines Prof Aboubakr Elnashar Benha university, Egypt Email: [email protected]

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Transcript of Heavy menstrual bleeding NICE Guidelines, Aboubakr Elnashar

Page 1: Heavy menstrual bleeding NICE Guidelines, Aboubakr Elnashar

Heavy menstrual

bleeding

NICE Guidelines

Prof Aboubakr Elnashar Benha university, Egypt

Email: [email protected]

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•HMB Excessive MBL which interferes with the woman’s

physical, emotional, social & material quality of life,

and which can occur alone or in combination with

other symptoms.

Any interventions should aim to improve quality of

life.

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History 1. Nature of the bleeding

2. Related symptoms that might suggest structural or

histological abnormality

3. Impact on quality of life

4. Other factors that may determine treatment

options (such as presence of comorbidity).

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•If the history suggests HMB without structural or

histological abnormality:

pharmaceutical treatment can be started without

carrying out a physical examination or other

investigations, unless the treatment chosen is LNG-IUS. •If the history suggests HMB with structural or

histological abnormality (intermenstrual or

postcoital bleeding, pelvic pain and/or pressure

symptoms):

Physical examination and/or other investigations

(US) should be performed.

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•Measuring MBL either directly (alkaline haematin)

or indirectly (Pictorial blood loss assessment chart)

is not routinely recommended.

{Whether MBL is a problem should be determined

not by MBL but by the woman herself}.

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Pictorial blood loss chart: (Higham,1990)

Days of the bleeding Score

1 2 3 4 5 6 7 8

Towel

1 ponit

5 ponits

10 points

Clots 1p clot 1 point

5p clot 5 points

Flooding 5 points

Score >100 = Menorrrhagia

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Examination •Indications: Before

1. LNG-IUS fittings

2. Investigations for structural abnormalities

3. Investigations for histological abnormalities.

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Laboratory tests •A full blood count test should be carried out

•Testing for coagulation disorders (von Willebrand’s

disease) should be considered

1. HMB since menarche

2. Personal or family history suggesting a

coagulation disorder.

•A serum ferritin test should not routinely be carried

out

•Hormone testing should not be carried out

•Thyroid testing should be carried out only when

other S&S of thyroid disease are present.

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Structural and histological investigations •Biopsy {exclude endometrial cancer or atypical

hyperplasia}.

Indications:

1. Persistent intermenstrual bleeding

2. Age 45 & over

3. Failure or ineffective treatment.

Advantages:

1. An outpatient procedure

2. No general anesthesia.

3. Complications are rare

An adequate & acceptable screening procedure

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Types

Reusable:

Vabra aspirator (95%)

Sharman curette,

Novak curette (90%),

Kevorkian

Randall

Disposable

Pipelle curette (90%)

Accurette

Z-sampler (83%),

Mi-Mark Helix (93%),

Endopap (70%),

Perma curette (73%)

Endorette

Explora (70%)

Karman (95%)

Ti-Utrap

Gynocheck

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Pipelle:

Is tolerated better than most other forms

Samples 4.2% of the endometrial surface

Detection rate of endometrial cancer: 90%

Vabra aspiration: Only samples 42% of the endometrial surface Less tolerated than other forms Compared with curretage, complications are less & the detection rate of endometrial abnormalitis are higher (Grimes,1982)

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Novak curette

Kevorkian curette

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Endocurette Pipelle

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•US is the first-line diagnostic tool for identifying

structural abnormalities.

•US should be undertaken when:

1. The uterus is palpable abdominally.

2. Vaginal exam: a pelvic mass of uncertain origin.

3. Pharmaceutical treatment fails.

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•Hysteroscopy should be used as a diagnostic tool

only when US results are inconclusive (for example,

to determine the exact location of a fibroid or the

exact nature of the abnormality).

•Saline infusion sonography should not be used as a

first-line diagnostic tool.

•MRI should not be used as a first-line diagnostic

tool.

•Dilatation & curettage alone should not be used as a

diagnostic tool.

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Pharmaceutical treatments •Indications:

1. No structural or histological abnormality

2. Fibroids

< 3 cm

no distortion of the uterine cavity.

•Determine she wish to conceive or not

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•Treatments should be considered in the following order:

a) LNG-IUS provided long-term (at least 12 ms) use

is anticipated

b) Tranexamic acid (3-6 gm/d for the first 3 days of

the cycle)

or NSAIDs (Mefenamic acid 500 mg tds during

menses).

or COCs

c) Norethisterone (15 mg daily, D5-26 of the cycle)

or injected long-acting progestogens

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Mirena

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•When HMB coexists with dysmenorrhoea, NSAIDs

should be preferred to tranexamic acid.

•Ongoing use of NSAIDs and/or tranexamic acid is

recommended for as long as it is found to be

beneficial by the woman.

•Use of NSAIDs and/or tranexamic acid should be

stopped if it does not improve symptoms within 3

menstrual cycles.

•When a first pharmaceutical treatment has proved

ineffective, a second pharmaceutical treatment can

be considered rather than immediate referral to

surgery.

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•GnRHa: could be considered

1. Prior to surgery or

2. When all other treatment options for fibroids,

including surgery or UAE, are contraindicated.

If this treatment is to be used for >6 ms or if

adverse effects are experienced then HRT‘add-

back’ therapy is recommended.

•Danazol should not be used routinely (200 mg/d)

•Oral progestogens given during the luteal phase

only should not be used.

•Etamsylate should not be used.

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Side effects

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Non-hysterectomy surgery Endometrial ablation

Indicated:

Bleeding having a severe impact on a woman’s

quality of life, and she does not want to conceive in

the future.

Types:

Balloon thermal endometrial ablation

Microwave endometrial ablation,

Free fluid endometrial ablation

Impedance-controlled bipolar radiofrequency

ablation

Endometrial cryotherapy is not covered by this

guideline.

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•Endometrial ablation

Indications:

1. Initial treatment after full discussion with

the woman of the risks & benefits and of

other treatment options.

2. Small uterine fibroids (<3 cm).

3. Uterus no bigger than a 10-week

pregnancy, endometrial ablation should

be considered preferable to hysterectomy.

Advise after endometrial ablation

Avoid subsequent pregnancy and use

effective contraception, if required

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•Second-generation ablation techniques should be

used where no structural or histological abnormality

is present.

•The second-generation techniques:

• Impedance-controlled bipolar radiofrequency

ablation

• Fluid-filled thermal balloon endometrial ablation

(TBEA)

• Microwave endometrial ablation (MEA)

• Free fluid thermal endometrial ablation

•In TBEA, endometrial thinning is not needed.

•In MEA, scheduling of surgery for postmenstrual

phase is an alternative to endometrial thinning.

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First-generation ablation techniques

Rollerball endometrial ablation [REA] Transcervical

resection of the endometrium [TCRE])

are appropriate if hysteroscopic myomectomy is to

be included in the procedure.

Dilatation and curettage

should not be used as a therapeutic treatment.

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Treatment of large fibroids (>3cm): • With significant symptoms (dysmenorrhoea or

pressure symptoms): surgery or UAE as first-line

treatment.

•UAE, myomectomy or hysterectomy: bleeding

having a severe impact on quality of life.

•Women should be informed that UAE or

myomectomy may potentially allow them to retain

their fertility.

•Myomectomy: Woman wants to retain their uterus.

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•UAE: Woman wants to retain their uterus and/or

avoid surgery.

•Prior to scheduling of UAE or myomectomy, the

uterus & fibroid(s) should be assessed by US. If

further information about fibroid position, size,

number and vascularity is required, MRI should be

considered.

•Pretreatment before hysterectomy and

myomectomy with GnRha for 3 to 4 ms should be

considered where uterine fibroids are causing an

enlarged or distorted uterus.

•If a woman is being treated with GnRha & UAE is

then planned, GnRHa should be stopped as soon

as UAE has been scheduled.

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Hysterectomy •Should not be used as a first-line treatment solely

for HMB.

Indications:

1. Other treatment options have failed,

contraindicated or declined by the woman

2. There is a wish for amenorrhoea

3. Woman (who has been fully informed) requests it

4. Woman no longer wishes to retain her uterus and

fertility.

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•Discussion of the implication of hysterectomy:

1. Sexual feelings, fertility impact, bladder function,

need for further treatment, treatment complications,

the woman’s expectations, alternative surgery and

psychological impact.

2. Increased risk of serious complications (such as

intraoperative haemorrhage or damage to other

abdominal organs)

3. Risk of possible loss of ovarian function and its

consequences, even if their ovaries are retained

during hysterectomy.

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•Route of hysterectomy. The following factors need

to be taken into account:

1. Other gynaecological conditions or disease

2. uterine size

3. presence and size of uterine fibroids

4. mobility and descent of the uterus

5. size and shape of the vagina

6. history of previous surgery.

•Taking into account the need for individual

assessment, the route of hysterectomy should be

considered in the following order: first line vaginal;

second line abdominal.

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•Morbid obesity or the need for oophorectomy during

vaginal hysterectomy: laparoscopic approach should

be considered, and appropriate expertise sought.

•When abdominal hysterectomy is decided upon then

both the total method and subtotal method should be

discussed with the woman.

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•Removal of healthy ovaries at the time of

hysterectomy should not be undertaken

•Removal of ovaries should only be undertaken with

the express wish and consent of the woman.

•Women with a significant family history of breast or

ovarian cancer should be referred for genetic

counselling prior to a decision about oophorectomy.

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•In women under 45 considering hysterectomy for

HMB with other symptoms that may be related to

ovarian dysfunction (for example, premenstrual

syndrome), a trial of pharmaceutical ovarian

suppression for at least 3 months should be used as

a guide to the need for oophorectomy.

•If removal of ovaries is being considered, the

impact of this on the woman’s wellbeing and, for

example, the possible need for HRT should be

discussed.

•Women considering bilateral oophorectomy should

be informed about the impact of this treatment on

the risk of ovarian and breast cancer.

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Investigate routine use of indirect measurements

of MBL in primary and secondary care

Evidence shows that direct measurement of MBL is

accurate but complex to undertake in clinical

practice, and that subjective assessment of MBL is

inaccurate but easy to undertake in clinical practice.

An alternative is the use of indirect measures of

MBL, such as the ‘Pictorial blood loss assessment

chart’. However, evidence on the use of indirect

measures is contradictory & no data are available to

show whether they could be used in routine practice.

If indirect measures are shown to work then they

could be introduced as a simple technique for

assessing MBL, and from this the management of

HMB could be improved.

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What are the long-term recurrence rates of

fibroids after UAE or myomectomy?

Both UAE and myomectomy are undertaken to

reduce symptoms associated with uterine fibroids by

directly removing the fibroid(s) or reducing their size.

Data exist on short- and medium-term recurrence of

fibroids, but no data are available on long-term

recurrence.

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What are the effects of hysterectomy and

oophorectomy on the occurrence of cancer?

Epidemiological studies are required to investigate

the impact of hysterectomy and oophorectomy on

cancer. The results of this research will have

fundamental implications on the use of these

treatments.

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