Mr James Campbell FRCOG

Background - Menstrual disorders

  1 in 20 women aged 30-49 present to their GP per year £ 7 million (!) is spent per year on primary care prescriptions  One of the most common reasons for specialist referral  Accounting for a third of gynaecological outpatient workload

Heavy menstrual bleeding (HMB)

    Major impact on health-related quality of life  22% of otherwise healthy women Major problem in public health   significant cost invasive treatments 12% of all specialist referrals Main presenting symptom for half of the hysterectomies performed in the UK Vessey M et al. The epidemiology of hysterectomy: findings of a large cohort study. Br J Obstet Gynaecol 1992;

99

; 402-407.

Increasing prevalence

 More periods per lifetime  Earlier menarche  Increased life expectancy  Ability to regulate fertility  Less time spent breastfeeding  More demanding lifestyles and reduced tolerance of troublesome periods

Menstruation

Shedding of the superficial layers of the endometrium following the withdrawal of ovarian steroids

Normal menstruation

 Menarche  Menopause  Regular cycles  Menstrual loss  Pelvic discomfort - 13 years - 51 years – 5 / 28 – 40ml (<80ml)

Menstrual disorders

 Heavy menstrual bleeding (HMB)   Intermenstrual / Postcoital bleeding Dysmenorrhoea = ‘painful periods’  Premenstrual tension (PMT)  Post-menopausal bleeding  Oligo- or Amenorrhoea

HMB - Etiology

    Endometrial origin  Increased fibrinolysis and prostaglandins Uterine / pelvic pathology    Fibroids / Polyps Pelvic infection (Chlamydia) Endometrial or cervical malignancy Medical disorders  Coagulopathy / Thyroid disease / Endocrine disorders Iatrogenic (anti-coagulation / copper IUCDs)

Clinical evaluation & management

Patient presenting with heavy menstrual bleeding

TAKE A HISTORY

Relevant history

 Frequency and intensity of bleeding – Menstrual diary  Pelvic pain / Pressure symptoms  Abnormal vaginal discharge  Sexual and contraceptive history  Obstetric history  Smear history  History of coagulation disorder

Examination

 Clinical examination  General appearance (? Pallor)  Abdominal examination (?Pelvic mass)  Speculum examination  Assess vulva, vagina and cervix  Bimanual examination  Elicit tenderness  Elicit uterine / adnexal enlargement

Investigations

 Indicated if age > 40 years or failed medical treatment  FBC / Coagulation screen  Thyroid function (only if clinically indicated)  Smear / Endocervical swabs / High vaginal swabs  Pelvic ultrasound (USS)  Saline hysterosonography (?Polyps)  Hysteroscopy  Endometrial biopsy (Pipelle / D&C)

Hysteroscopy

Endometrial biopsy

Endometrial Hyperplasia WHO Classification  Simple hyperplasia No risk of malignant transformation  Complex hyperplasia Low risk (~5%)  Simple atypical hyperplasia Unknown risk  Complex atypical hyperplasia Significant risk (at least 30%)

Endometrium: simple hyperplasia

Complex non-atypical hyperplasia

Complex atypical hyperplasia

Causes of HMB

Endometrial origin

“Dysfunctional uterine bleeding”

Anovulatory Cycles Reasons for heavy menstrual bleeding      Endometrium develops  under the influence of oestrogen Corpus luteum fails to develop  absence of progesterone Spiral arteries do not develop properly and are unable to undergo vasoconstriction at the time of shedding Endometrium supplied by thin-walled vessels Result – prolonged heavy bleeding

Persistent Anovulation

 Infertility  Endometrial hyperplasia  Increased risk of endometrial carcinoma

Management of HMB

       Anti-fibrinolytics  Tranexamic acid (Cyclokapron ®) Prostaglandin synthetase inhibitor  Mefenamic acid (Ponstan®) Combined oral contraceptive pill (COC) Progestogens GnRH analogues Endometrial ablation Hysterectomy

Management - Progestogens

 Luteal phase progestogens (only useful if anovulatory)  Long-acting progestogens (Depoprovera / Implanon)  Mirena IUS

Mirena IUS

Endometrial ablation

 Day-case procedure or out-patient setting  1 st generation   Trans-cervical resection 2 nd generation  Thermal balloon  Microwave  Impedance controlled  Similar outcome to Mirena IUS

Hysterectomy

 “Treatment of choice for cancer, but a choice of treatment for menorrhagia” Lilford RJ (1997) BMJ 314; 160 - 161  Surgical access  Total versus subtotal hysterectomy  Removal versus conservation of ovaries and use of HRT

Abdominal hysterectomy Vaginal hysterectomy

Uterine pathology

Evaluation & Management Polyps and Fibroids

Endometrial polyps

       Localised overgrowths of endometrium projecting into uterine cavity Common in peri- and postmenopausal women (10 – 24% of women undergoing hysterectomy) Account for 25% of abnormal bleeding in both pre- and postmenopausal women Typically benign, but malignant change can rarely occur Non-neoplastic lesions of endometrium containing glands, stroma and thick-walled vessels Glands may be inactive, functional or hyperplastic Association with tamoxifen use

Endometrial Polyp

Endometrial polyps

 Diagnosis  Pelvic USS / Saline hysterosonography  Hysteroscopy  Management  Operative removal with polyp forceps / curette or hysteroscopic resection

Uterine Fibroids

(Leiomyomata)  Occur in 20 – 30% of women over 30 years  Usually multiple  Almost invariably benign  Variable sizes, up to 20 cm or more  Sex steroid-dependent – regress after the menopause

Submucosal uterine fibroid

Leiomyoma with central degeneration

Leiomyoma

Uterine fibroids

  Symptoms   50% asymptomatic HMB / Dysmenorrhoea    Pressure effects Infertility Pregnancy complications Diagnosis   Clinically enlarged uterus Pelvic USS  Hysteroscopy / Laparoscopy

Uterine fibroids - Management

   Conservative  Ensure Dx of fibroids and R/O adnexal mass Medical  Tranexamic acid / NSAIDs   Mirena IUS GnRH agonists Surgical  Myomectomy   (hysteroscopic / laparascopic / by laparotomy) Hysterectomy Uterine artery embolization

Postmenopausal bleeding

Evaluation

Postmenopausal bleeding (PMB)

 ALL WOMEN WITH PMB MUST BE INVESTIGATED  Purpose of investigation: Exclude malignancy of endometrium and cervix  Endometrial Ca in up to 4% of women with PMB  Precursors of endometrial Ca (complex hyperplasia +/- atypia)

PMB – Exclude malignancy

     History and assessment of risk factors  Use of HRT / Tamoxifen / BMI / Family Hx Clinical Examination (!)  R/O cervical carcinoma Trans-vaginal USS  Assessment of endometrial thickness (<3mm) Endometrial sampling (+/- uterine evaluation) Treatment for endometrial Ca  Hysterectomy +/- radiotherapy

Endometrial Carcinoma

  Type I      Oestrogen dependent 80% Low grade Endometrioid histology Assoc with obesity (40%), nulliparity, late menopause, tamoxifen Type II       Non-oestrogen dependent Older postmenopausal women High grade Serous, clear cell and mixed histology Tamoxifen; no association with hyperoestrogenism or hyperplasia Aggressive behaviour

Endometrioid carcinoma

Endometrioid Carcinoma

Endometrial Carcinoma

Prognostic Factors  Histological type  Histological grade  Depth of myometrial invasion  Lymphovascular space invasion  FIGO stage

Case 1

 43 year old, para 2 + 0, company executive  Presenting complaint   excessive menstrual blood loss requirement for contraception  History    Menarche aged 13 years Used OC pill until 35 years Smokes 15 / day  Examination  Normal sized uterus and normal adnexae

Case 2

 38 year old, para 0 + 0, primary school teacher  Presenting complaint  excessive menstrual blood loss and dysmenorrhoea  History    Menarche aged 12 years Used OC pill until 25 years Currently using tranexamic acid with unsatisfactory effect  Examination  Uterus appears enlarged to 18/40 size

Case 3

 59 year old, para 0 + 0, retired  Presenting complaint  vaginal bleeding on two occasions over last 3 months  History     Menopause aged 49 years Polycystic ovarian syndrome Infertility BMI = 38 / Overweight for many years

 How would you evaluate this case?

 Would you carry out any investigations?

 What management options would you discuss and recommend?