Transcript Document

Abnormal Uterine
Bleeding
Emma Readman
Gynaecologist, Endosurgeon
Endosurgery 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
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Increased bleeding:
pathogenesis
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Structural Vs Functional
Structural –EXCLUDE PREGNANCY
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IUDs
Polyps
Fibroids
  bleeding by endometrial surface area
 30% 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
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Endometrial cancer
Endometrial hyperplasia
Menstrual cycle
Functional bleeding
Functional:
 Ovulatory Vs Anovulatory
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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
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Anovulatory Bleeding:
Systemic in nature: hypothalamopituitary-ovarian axis
 Also local haemostatic mechanisms
rendered deficient
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Menorrhagia: Pathogenesis
Also bleeding disorders:Von
Willebrande’s Disease 10.7% in
women with menorrhagia(US
centres disease control and
prevention)
 Enhanced fibrinolysis
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Clinical evaluation
Abnormal bleeding
examine
US, pap, FBE
Regular heavy
N US, pap, FBE
Irregular heavy
PCB/IMB/PMB
abN of pap, US
trial of
tranexamic acid
NSAID(esp if pain)
+/- OCP
LH, FSH, TFTs
prolactin, sens test,
FAI, shbg
if long term, may need curette
refer
specialist
Medical Options
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Fe therapy
Antifibrinolytics
Cyclo-oxygenase inhibitors
Progestins
Continuous/cyclic
Local
Inplantable
Oestrogens plus progestins
Androgens
GNRH agonists and antagonists
Antifibrinolytics
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Tranexamic acid 1g QID first 4 days cycle
for ovulatory DUB
Virtually all cases bleeding reduces 4060%
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)
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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
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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
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Progestins:Local
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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
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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
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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
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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
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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
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Nonhysteroscopic
endometrial ablation
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Radiofrequency electrosurgical:
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Local hyperthermia:
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Vestablate
Novasure
Cavaterm
HydroThermAblator
Thermachoice
Cryotherapy
Microwave
Novasure
Randomised trials comparing
HER/ablation & hysterectomy
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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 up40% reoperation rates
Alternative therapies
garlic
 Panax ginseng
 Chaste tree
 Wild yam
 Cramp bark
 Helionas root
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Alternative therapies
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Garlic
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Inhibits platelet aggregation in a dose
dependent fashion
Increased fibrinolysis
Discontinue use 7 days prior to surgery
Advise against use if low platelets
Ginseng
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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
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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
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Case three
Ms PV is a 45 year old
 Heavy irregular periods increasing
over last 2 years
 Some hot flushes
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