Abnormal Uterine BleedingWhat to do about it?Richard Eden, M.D.

www.SpringfieldClinic.comwww.SpringfieldClinic.com

Abnormal Uterine Bleeding Affects…

• Adolescents

• Women of reproductive age

• Perimenopausal and postmenopausal women

Abnormal Uterine BleedingDefinitions

• Menorrhagia-heavy or prolonged uterine bleeding that occurs at regular intervals. Usually >7d or >80 ml blood loss.

• Oligomenorrhea-cycle length >35 days• Polymenorrhea-cycle length < 21days• Amenorrhea-absence of menstruation for at least 6 months.• Metrorrhagia-irregular menstrual bleeding or bleeding

between periods. Usually normal or reduced flow.• Menometrorrhagia-irregular menstrual bleeding with

excessive volume and duration of flow.

EndometriumEndometrium

MyometriumMyometrium

MenorrhagiaExcessive Menstrual Bleeding

CervixCervix Abnormal bleeding is defined by: Length of cycle (days)

Duration of menses (days)

Amount of blood loss (ml)

Normal Menses

Normal Abnormal

Duration of flow 4-6 days >7days

Volume of flow 35 ml >80 ml

Length of cycle 21-35 days

Uterus

• Hollow, pear-shaped muscular organ, which lies in the pelvic cavity, between the urinary bladder and the rectum

• Functions to prepare for and maintain pregnancy

Laparoscopy-Normal Uterus

Normal Uterus & Right Ovary/Tube

Normal Uterus & Left Ovary/Tube

Abnormal Uterine Bleeding

• Affects >10 million women in the U.S.

• Impacts daily activities and quality of life

• May cause anxiety

• May lead to iron-deficiency anemia/fatigue

Normal Menstrual Cycle

Abnormal Uterine BleedingDifferential Diagnosis

• Structural-Cervical or vaginal

laceration-Uterine or cervical

polyp-Uterine leiomyoma

(fibroids)-Adenomyosis-Cervical

stenosis/Asherman’s (hypomenorrhea)

Abnormal Uterine Bleeding Differential Diagnosis

• Hormonal -Anovulatory bleeding (lack of ovulation-decreased

progesterone) -Hypogonadotropic hypogonadism -Pregnancy -Hormonal contraception (BCP’s, Depo-Provera)• Malignancy -Uterine or Cervical cancer -Endometrial hyperplasia (potentially pre-malignant) -Chemotherapy or radiation• Bleeding Disorders -VonWillebrand’s Disease, Hemophilia, ITP, Factor deficiencies, platelet disorders.

Abnormal Uterine Bleeding Workup

• History -Timing of bleeding, quantity of bleeding, menstrual history, associated symptoms. Family history of bleeding disorders. Excessive psychological stress, exercise, or weight loss.• Physical Exam -pap smear (rule out cervical cancer) -endometrial biopsy (rule out uterine cancer) -excessive facial hair growth, obesity (BMI>25) (polycystic ovarian disease 6-10% of women) -abnormal breast discharge (prolactin disorders) -anorexia signs (hypothalamic dysfunction) -goiter, weight loss or gain (thyroid disease) -other disease states (leukemia, hypersplenism, chemo, radiation)• Labs -Pregnancy test -FSH, LH, Estradiol -TSH, Prolactin, DHEA-S, Testosterone• Imaging -Pelvic ultrasound (transvaginal) -Sonohystogram (saline infusion ultrasound) or hysterosalpingogram (x-ray) -MRI (better for adenomyosis dx than U/S)• Surgical -Hysteroscopy -D&C

Medical Treatment of Abnormal Uterine Bleeding

• Iron• NSAID’s• Combined Contraceptives (estrogen and

progesterone)• Progesterone only methods• IV Estrogen• GnRH agonists• Androgens• Antiprogestational agents

Iron

• Menstrual volume > 60 ml- iron deficiency anemia

• Primary symptom is fatigue• Daily doses of 60-180 mg of iron needed for

anemia Rx• May be the only treatment necessary

NSAID’s

• Nonsteroidal Anti-inflammatory Drugs

• Can decrease bleeding by 30-40%

• Motrin (ibuprofen) 400mg every 4 hrs

• Anaprox (Naproxen) 550 mg every 12 hrs

Combined Contraceptives

• Contain both estrogen & progesterone

• Birth control pills (daily)

• Birth control patch Ortho Evra (weekly)

• Contraceptive ring Nuvaring (monthly)

NuvaRing

Progesterone only Methods

• Mini-pill-often used in breastfeeding moms, useful in patients who cannot take estrogen containing pills (Hx of strokes, DVT’s, breast cancer).

• Depo-Provera-3 month birth control, high amenorrhea rate, causes weight gain, causes increased bone loss.

• Progesterone sub dermal implants (Implanon)-3 year birth control. High irregular bleeding rates during the first few months.

• Progesterone IUD (Mirena)-5 year birth control, 70-80% reduction in blood loss, 99.8% effective contraception, 3-5 minute office procedure. Same bleeding rate control as ablations after 2-3 years of use.

Implanon

Mirena IUD

Other treatments

• IV Estrogen—stops bleeding acutely (71% bleeding cessation vs. 38% placebo), usually within 24-48 hrs, given in hospital setting. Premarin 25 mg IV q 4 hrs x 24 hrs.

• Lupron (GnRH agonist)—induces amenorrhea in 40-60% of patients by shrinking total uterine volume. Limited use due to cost and “menopause-like” side effects. Mostly used for fibroid related bleeding prior to surgery.

• Androgens (Danazol)—synthetic testosterone derivative, reduces bleeding volume 50% in women with ovulatory bleeding. Side effects make long term treatment undesirable.

• Antiprogestational Agents (Mifepristone 50 mg/day)—reduces the number of progesterone receptors in the uterus. Reported to induce amenorrhea in women with fibroids.

Endometrial Ablation

• Surgical procedure-outpatient surgical setting, usually general anesthesia.

• Indicated for the treatment of menorrhagia or perceived heavy menstrual bleeding in premenopausal women (usually< age 50).

• Presence of anemia or failed medical therapy are other indications for endometrial ablations.

• Goal is to normalize menstrual blood flow.• Contraindicated in postmenopausal bleeding patients.• Not a contraceptive method.• Must be done with childbearing (previous tubal or

vasectomy).• Tubal ligation can be done the same day as the ablation

surgery.

Ablation Preoperative Evaluation

• Pap smear-used to exclude cervical cancer• Endometrial biopsy-used to exclude uterine cancer

or uterine hyperplasia.• Transvaginal U/S-used to look for anatomic causes

of bleeding such as uterine fibroids, uterine polyps, cervical polyps, or congenital malformations of the uterus (septate uterus). Often combined with saline infusion sonography (SIS).

• Hysteroscopy-using a camera to look “inside” the uterine cavity.

• D&C –dilation & curettage-scrapping uterine lining.

Endometrial Biopsy

• Safe, relatively simple procedure useful in perimenopausal or high risk women

• Not sensitive for detecting structural abnormalities (eg, polyps or fibroids)

• Office-based techniques (gold standard replacing D&C)– Disposable devices (eg, Pipelle, Tis-u-Trap,

Accurette, Z-sampler)– Reusable instruments (eg, Novak Curette,

Randall Curette, Vabra Aspirator)

Transvaginal Ultrasonography (TVS)

– Inexpensive, noninvasive, and convenient • Indirect visualization of the endometrial

cavity, myometrium, and adnexa • Measurement of endometrial thickness

(<5 mm vs. >5 mm)• May be used to increase index of

suspicion for endometrial atrophy, hyperplasia, cancer, leiomyomas, and polyps

• May not always distinguish among submucosal fibroid, polyp, or adenomyosis

Posterior Fibroid

Slide courtesy of Linda Bradley,MD.

Saline Infusion Sonography (SIS)

• Relatively new technique• Very useful for evaluation of AUB in pre-, peri-, and

postmenopausal women• May be superior to TVS alone (94.1% vs. 23.5% for

detection of focal intrauterine pathology)• SIS + biopsy: 96.2% sensitivity and 98% specificity • Disadvantage: small irregularities may be

misinterpreted as polyps • Able to determine penetration depth of uterine

fibroids

Saline Infusion Sonography

Posterior Fibroid

Slide courtesy of Linda Darlene Bradley, MD.

Submucosal Fibroid

Slide courtesy of Linda Darlene Bradley, M.D.

Endometrial Polyps

Slide courtesy of Linda Darlene Bradley, MD.

Hysteroscopy

• Hysteroscopy + biopsy = “gold standard” • Most are performed to evaluate AUB • Diagnostic hysteroscopy easily performed in

the office setting—although it requires skill • Particularly useful in the diagnosis of

intrauterine lesions in women of reproductive age with ovulatory AUB

• Complications (<1%) may include uterine perforation, infections, excessive bleeding, and those related to distending medium

Hysteroscopy = Uterine Camera

Flexible hysteroscope

Normal Uterine Cavity

Uterine septum

Endometrial Polyps

Slide courtesy of Linda Darlene Bradley, MD.

Vascular endometrial polyp

Uterine Polyp

Uterine Polyp

Large Uterine Polyp

Uterine Cavity Post Resection of Polyp

Uterine Polyps

Endometrial Hyperplasia

rSSlide Courtesy of Linda Darlene Bradley, MD.

Uterine Submucosal Fibroid

Resection of uterine fibroid

Ablation Devices

• Novasure—uses radiofrequency electricity with a bipolar gold mesh electrode. The device is passed through the cervix and into the uterine cavity.

• Ablation cycle takes 80-90 seconds. Very fast.

• 78% Success rate• 35-41% amenorrhea rate• 92% patient satisfaction rate at 1 year

Step 1

After slightly dilating your cervix and inserting a slender wand, your doctor will extend a triangular mesh device into your uterus.

Step 2

The mesh device gently expands, conforming to the dimensions of your uterine cavity.

Step 3

Electrical energy is delivered through the mesh for approximately 90 seconds.

Step 4

The mesh device is retracted back into the wand and both are removed from your uterus.

Novasure Endometrial Ablation

Thermachoice Endometrial Balloon

ThermaChoice Balloon

Ablation Devices

• Thermachoice—balloon tipped catheter is positioned into the uterine cavity and filled with fluid that is heated to 87 degrees centigrade.

• Ablation cycle takes 8 minutes.• May be better suited for fibroid uterus.• Reported to decrease menstrual cramps

better.• 80 % success rate• 37% amenorrhea rate at one year• 96% patient satisfaction rate

Ablation Complications

• UTI 0.8-3 %• Vaginal infection 0.6-2.3%• Fever 1.4%• Endometritis 1-2.8 %• Abdominal pain/cramps 0.6-3.2%• Hematometra 0.6 %• Bacteremia 0.5%• Uterine perforations 1.4%• Fluid overload 0.2%• Postablation tubal ligation syndrome 1-10%• Electrolyte imbalance• Cervical laceration

Contraindicatons to Ablation

• Large uterus > 12 wks size• Uterine fibroids > 3 cm• Uterine cancer or uterine hyperplasia• Postmenopausal females• Recent pregnancy (must be at least 6 wks

postpartum)• Desire for future pregnancy• Active or recent uterine infection (PID)• Previous uterine surgery (C/S or myomectomy)• Anatomic distortion (congenital uterine

malformations—bicornuate uterus, etc.)

Effectiveness of Ablation

• >90 % patient satisfaction at 1 year• 37-41% amenorrhea rate• About 10% dissatisfaction rate at one year• 2-3 % have repeat ablations after one year• 6-10% will have subsequent hysterectomy

after one year• Some studies report 8% to 24% subsequent

hysterectomy rates at 7 years post ablation

Endometrial Ablation Summary

• Endometrial ablations are effective treatment for abnormal uterine bleeding

• Outpatient procedure• >90% patient satisfaction rate• High amenorrhea rate• Estimated that endometrial ablations

will replace 30% of all hysterectomies done in U.S.

Hysterectomy Facts

• Most common female surgery• Definitive solution for many uterine

conditions• 650,000 procedures annually

Most performed through abdominal (open) incision

• Advances in minimally invasive surgery (MIS) for hysterectomyMore GYN surgeons performing MIS for

hysterectomy

Hysterectomy

• Total abdominal hysterectomy (TAH)

• Vaginal hysterectomy

• Laparoscopic assisted vaginal hysterectomy (LAVH)

• Laparoscopic supracervical hysterectomy (LSH)

• Total laparoscopic hysterectomy (TLH)

• Open (abdominal) surgery

• Minimally invasive surgery (MIS)Vaginal surgeryConventional laparoscopic surgeryda Vinci® Hysterectomy (robot-assisted

surgery)

Surgical Approaches to Hysterectomy

Minimally Invasive Surgery (MIS)

• Reduced blood loss• Fewer complications• Shorter Hospital stay• Faster recovery• Less scarring

Circa. 1991

Vaginal Surgery

Pros• Minimally invasive

Minimal scarring Short hospital stay Less pain compared to abdominal hysterectomy

Cons• Difficult to perform• Reduced visualization• Not indicated for many patients

Nulliparious (women who have not given birth) Multiple fibroids (or large masses) Cancer Adhesions, e.g., endometriosis, prior pelvic surgery

Minimally invasive Ability to operate through small, keyhole incisions

Better visualization than open surgery

Open Vertical Incision Open Transverse Incision Laparoscopic or

da Vinci® Incision

Laparoscopic Surgery

Drawbacks with Conventional Laparoscopic Surgery

• Surgeon operates from a 2D image

• Rigid instruments

• Instruments controlled at a distance

• Reduced dexterity, precision & control

• Greater surgeon fatigue

• Surgical assistance is limited

• Makes complex operations more difficult to perform

How can we overcome these drawbacks?

da Vinci® Surgical System

• State-of-the-art robotic technology

• Surgeon in control• Assistant has direct

access

Vision System

Surgeon immersed in 3D image of the surgical field

Surgeon directs precise movements of the instruments using Console controls

The Surgeon Directs the Instruments

• Conventional minimally invasive instruments are rigid with no wrists

• EndoWrist® Instrument tips move like a human wrist

• Allows surgeon to operate with increased dexterity & precision

Wrist and Finger Movement

• EndoWrist® Instruments fit through dime-sized incisions

• A wide range of instruments are available

Small Instruments, Small Incisions

Surgeon has… Improved visualization Better instrumentation,

surgical control & precision Better surgical dexterity for

complex aspects of procedure

Easier & faster suturing Better ergonomics

Double-click to view video

da Vinci® Surgery

Open Vertical Incision Open Transverse Incision da Vinci® Surgical Incision

Robot-Assisted Surgery Access

da Vinci® Gynecologic Surgery Indications

• da Vinci® Surgery appropriate for a broader range of gynecologic conditions & patient situations compared to conventional laparoscopy• Cervical cancer

Conventional laparoscopy not widely accepted• Endometrial cancer

Conventional laparoscopy accepted, but technically difficult to perform

• Vaginal or uterine prolapse Conventional laparoscopic suturing not reliable

• Endometriosis• Uterine fibroids• Obese patients

Enable minimally invasive surgery (MIS) approach– Easier to learn & perform compared to conventional

laparoscopic surgery– da Vinci (robotic-assisted) Surgery will enable:

More Gynecologists to perform minimally invasive surgery

Gynecologists to perform more advanced operations & more types of procedures using a minimally invasive approach

Provide benefits of MIS to hysterectomy candidates– Short hospital stay– Minimal pain & scarring– Quick recovery & return to normal activities

Goals of da Vinci® Hysterectomy

daVinci Robotic Platform

My Girls

My Girls