Beruflich Dokumente
Kultur Dokumente
Menstruation
Menstruation is a
woman's
monthly bleeding
from her
reproductive
tract induced by hormonal changes of the menstrual cycle. The length of a menstrual
cycle is the time from the start of a period to the start of the next.
Beliefs derived from personal experience and cultural, social and educational influences
determine whether she perceives the menstrual blood loss to be 'normal' for her.
1
However, a 'normal' quantity of monthly blood loss (MBL) can be defined objectively for
the whole population.
Due to difficulties in determining when a menstrual period begins (e.g. spotting,
brown/pink discharge, continuous prolonged bleed), it is often difficult to differentiate
between a menstrual period and an intermenstrual bleed (IMB). In the main, the
aetiopathology and treatment of IMB differs from heavy menstrual bleeding (HMB).
Mean is 28 days (95% CI 2438 days); frequent <24 days, infrequent >38 days.
As age increases, the menstrual cycle tends to shorten; age 1319 years, mean cycle
length 35 days (90th centile range: 2844 days), age 3552 years, mean cycle length
28 days (90th centile range: 2532 days).
As age increases, the frequency of irregular periods reduces. The frequency of irregular
periods is around 21% between the ages 15 and 19 years and reduces 11% between
ages 40 and 44 years.
Duration of menstruation
Mean 40 ml (95% CI 580 ml); heavy is >80 ml; light is <5 ml.
In women with no pre-existing menstrual problems, the normal amount of monthly
menstrual blood loss (MBL) is 2550 ml. An early study showed that haemoglobin and
ferritin levels adversely changed at MBL levels beyond 80 ml and suggested this should
be considered the upper limit of the population average MBL.
A subsequent study showed that anaemia and iron depletion occurred at two points,
first around 60 ml MBL and then around 120 ml MBL. The study concluded that a
definition around 120 ml may be more useful for the management of women with HMB
as this correlated to when anaemia was most likely to occur.
Regularity of menstrual cycle (cycle to cycle variation over 12 months,
measured in days)
Regular cycle-to-cycle variation is between 220 days, irregular variation is >20 days or
absent.
Components used to describe type of AUB
Frequent
<24
Normal
2438
Infrequent
>38
Prolonged
>8.0
Normal
4.58.0
Shortened
<4.5
Heavy
>80
Normal
580
Median
40
Light
<5
Regular variation: 2 to 20
days
Irregular variation: >20 days
or absent
Connolly A, Jones SE. Nonmenstrual bleeding in woman under 40 years of age. The Obstetrician &
Gynaecologist 2004;6:1538.
Warrilow G, Kirkham C, Ismail K, Wyatt K, Dimmock P, OBrien S.Quantification of menstrual blood loss. The
Obstetrician & Gynaecologist 2004;6:8892.
Fraser IS, Critchley HOD, Munro MG, Broder M. Can we achieve international agreement on terminologies
and definitions used to describe abnormalities of menstrual bleeding? Hum Reprod 2007;22:635643.
Key points
Menstruation is controlled by the cyclical hormonal change in the menstrual
cycle.
Normal frequency is between 2438 days.
3
Definition of HMB
Heavy menstrual bleeding (HMB) is clinically defined as menstrual blood loss (MBL)
that is subjectively considered to be excessive by the woman and interferes
with her physical, emotional, social and material quality of life.
Quantifying monthly menstrual blood loss (MBL) does not improve clinical care and is
not undertaken in modern clinical practice. MBL may be estimated directly (e.g. by
collecting all sanitary protection and eluting and quantifying blood by laboratory
techniques such as the alkaline haematin test) or indirectly (e.g. Pictorial Blood Loss
Assessment Chart [PBAC]; subjective measures).
Objective assessment: a PBAC score greater than or equal to 100 equates to a
sensitivity of 86%91% and a specificity of 8289% in predicting MBL greater than 80
ml by alkaline haematin test (gold standard reference technique).
Subjective assessment: subjective assessment of MBL combines information of
sanitary protection usage, flooding, clots, duration of menstruation and the woman's
personal opinion of her menstrual loss. Although this tends to be inaccurate, it is easy
to undertake in clinical practice and is the preferred method of assessing HMB.
Prevalence of HMB
HMB has a major adverse effect on the quality of life of many women. Overall, 3% of
premenopausal women experience HMB. However, this absolute risk is almost doubled
in woman aged 4051. HMB accounts for around 15% of all secondary care
gynaecological referrals in the UK.
It is estimated that HMB costs the UK NHS around 100 million a year.
Greater awareness of HMB led by better
health education and expanding internet
resources has empowered women to seek
earlier medical advice and the expectation
of greater treatment choice.
Figure adapted from: National Institute of Health and Clinical Excellence. Heavy menstrual bleeding:
costing report. Implementing NICE guidance in England. London: NICE; 2007
Causes of HMB
Key points
Heavy menstrual bleeding is a subjective diagnosis as it is defined by the woman
based on how it interferes with her quality of life.
HMB affects 3% of premenopausal women.
Pathological causes of HMB include uterine fibroids (2030%), uterine polyps (5
10%), Adenomyosis (5%); endometriosis rarely presents as AUB, but is identified
in <5% of cases of AUB.
DUB should not be used to describe HMB.
(AUB)
Heavy
menstrual
bleeding (HMB)
Intermenstrual
bleeding (IMB)
Chronic AUB
AUB has been present for the majority of the past 6 months. In
most cases, chronic AUB is unlikely to require urgent immediate
clinical intervention
Acute AUB
Oligomenorrhoe Bleeding that occurs at intervals of >35 days and <6 months,
a
usually caused by a prolonged follicular phase
Polymenorrhoea Regular bleeding at intervals of less than 3 weeks, which may be
caused by a luteal phase defect
Amenorrhoea
Menometrorrha HMB at the usual time of menstrual periods and at other irregular
gia
intervals
Metrorrhagia
Dysfunctional
This may be ovulatory or anovulatory HMB. This is diagnosed after
uterine bleeding the exclusion of pregnancy, medications, iatrogenic causes, genital
(DUB)
tract pathology and systemic conditions
The terms listed in the table above, until now, have been widely accepted as
appropriate terms to describe AUB. However, there has been concern that such
terminology is poorly understood by both doctors and patients and is liable to
misinterpretation.
Fraser IS, Critchley HOD, Munro MG, Broder M. Can we achieve international agreement on terminologies
and definitions used to describe abnormalities of menstrual bleeding? Hum Reprod 2007;22:63543.
FIGO have approved this new classification system and have called it PALMCOEIN:
Reprinted from: Munro MG, Critchley HO, Broder MS, Fraser IS and the FIGO Working Group on Menstrual
Disorders. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid
women of reproductive age. Int J Gynaecol Obstet 2011;113:313 [Abstract], with permission from Elsevier
In general, the components of the PALM group are discrete (structural) entities
that can be measured visually with imaging techniques and/or histopathology,
whereas the COEIN group is related to entities that are not defined by imaging or
histopathology (non-structural).
The term 'dysfunctional uterine bleeding which was previously used as a
diagnosis for AUB that occurs in the absence of systemic or locally definable
genital tract pathology, should be discarded and is not included in PALM-COEIN.
Women who fit this description generally have any combination of coagulopathy,
ovulation or primary endometrial disorder.
The following illustrated table shows how diagnosed pathology can be described
used PALM-COEIN terminology.
Reprinted from: Munro MG, Critchley HO, Broder MS, Fraser IS and the FIGO Working Group on Menstrual
Disorders. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid
women of reproductive age. Int J Gynaecol Obstet 2011;113:313 [Abstract], with permission from Elsevier
The PALM-COEIN system can also include the Type O, 1, 2 submucosal fibroid
classification system (Wamsteker 1993 and ESGE), and expand this further to
intramural and subserosal location of fibroids. This is depicted in the figure
below.
Reprinted from: Munro MG, Critchley HO, Broder MS, Fraser IS and the FIGO Working Group on Menstrual
Disorders. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid
women of reproductive age. Int J Gynaecol Obstet 2011; 113:313 [Abstract], with permission from Elsevier
Type 8 fibroids are leiomyomas that do not relate to the myometrium and include
cervical or broad ligament fibroids without direct attachment to the uterus, as
well as other so-called 'parasitic' (extra-pelvic) lesions.
Munro MG, Critchley HO, Broder MS, Fraser IS and the FIGO Working Group on Menstrual Disorders. FIGO
classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of
reproductive age. Int J Gynaecol Obstet 2011;113:313 [Abstract].
Adenomyosis
Leiomyoma
Non-structural
C
10
Key points
Causes of AUB should be classified as per the PALM-COEIN model.
PALM causes (Polyps, Adenomyosis, Leiomyomas [subserosal and other],
Malignancy and hyperplasia) are structural.
COEIN causes (Coagulopathy, Ovulatory dysfunction, Endometrial, Iatogenic,
Not otherwise specified) are non-structural.
Establish if chronic AUB (>6 months) or acute AUB (urgent intervention required).
Recommendation for full blood count (FBC), cervical smear, pelvic infection
swabs and pelvic ultrasound (and coagulation screen if clinical question screen
positive).
12
13
1.
2.
3.
4.
5.
Although several assessment and treatment pathways for AUB have been published,
they essentially portray the same message. Initial assessment in primary care should
include:
history: specifically enquiring about menstrual history, pelvic pain, fertility,
symptoms of anaemia and impact on quality of life, risk factors for inherited
coagulopathy (e.g. von Willebrand disease)
abdominal and pelvic examination: specifically, a bimanual examination of the
uterus and speculum examination of the cervix, with cervical cytology sampling
undertaken if appropriate
genital tract infection screening if risk factors are present or
cervicitis/endometritis is suspected on history or examination.
FBC to check for anaemia
pelvic ultrasound if red flag features (see diagram above) are present.
National Institute for Health and Clinical Excellence. Heavy menstrual bleeding. NICE
clinical guideline 44. London: NICE; 2007.
NICE HMB care pathway
14
Characteristic
16
o
o
o
o
o
o
o
1.
2.
PCB
PMB
IMB
pelvic mass
cervix lesion
18
Persistent IMB
>45 years with treatment failure
Irregular bleeding while on hormonereplacement therapy or tamoxifen
Fibroids, adenomyosis
pelvic ultrasound
hysteroscopy
endometrial biopsy; either hysteroscopically directed or through 'blind' global
uterine cavity Pipelle sampling.
In addition to new AUB terminology and classification of AUB causes (PALM-COEIN),
FIGO also recommended an uterine/endometrial assessment care pathway (depicted
below).
19
Reprinted from: Munro MG, Critchley HO, Broder MS, Fraser IS and the FIGO Working
Group on Menstrual Disorders. FIGO classification system (PALM-COEIN) for causes of
abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol
Obstet 2011;113:313 [Abstract], with permission from Elsevier
Enlarge
Saline hysteroscopy
Hysteroscopy combined with endometrial biopsy improves the sensitivity and
specificity for detection of endometrial malignancy and other pathology compared with
either diagnostic tests performed alone.
The endometrial biopsy may either be taken under direct hysteroscopic vision (e.g.
using the 5 French operating channel of the hysteroscope and inserting a hysteroscopic
grasper or biopsy forceps) or in a non-directed 'blind' manner sampling all surfaces of
the uterine cavity e.g. Pipelle sampler.
20
Hysteroscopy has a sensitivity and specificity for identifying endometrial cancer of 86%
and 99%, respectively. Endometrial sampling alone has a sensitivity and specificity of
6881% and 99100% for identifying endometrial hyperplasia and endometrial cancer.
Saline infusion sonography
2D transvaginal pelvic ultrasound images of A) normal uterus and right ovay and B) a
normal uterus.
Saline infusion sonography (SIS) provides improved visualisation of uterine and
endometrial pathology. SIS involves an infusion of sterile saline through a soft, plastic
catheter placed in the cervix in conjunction with transvaginal ultrasound. The saline
infusion distends the uterine cavity.
Enlarge
21
SIS outlines the intrauterine polyp (Figure B), which could not be easily seen with in the
routine transvaginal pelvic ultrasound (Figure A).
Supplementary investigations
Consideration may be given to other investigations, which may be requested from both
primary and secondary care settings.
These are summarised in the table below.
Investigations supplementary to baseline set
MRI and endometrial
biopsy
Sonohysterography
(saline infusion
sonography)
Pelvic infection
screening
Von Willebrand's
disease (vWD)
Hysteroscopy
Assessment history:
Score
Total attempts:
Average score:
0%
For each complication listed below, choose the frequency of their occurrence when
undergoing diagnostic or operative hysteroscopy. Each option can be used once, more
than once or not at all.
A: < 1% frequency
22
B: < 5% frequency
C: 510% frequency
Cervical laceration.
Please Select
Primary haemorrhage.
Please Select
Fluid overload and dilutional hyponatraemia (particularly relevant with firstgeneration endometrial destruction techniques that used Glycine; now we
use bipolar resectoscopes that work in saline uterine distension media).
Please Select
Electrosurgical injury.
Please Select
Secondary haemorrhage.
Please Select
Postoperative infection.
Please Select
23
Vasovagal syncope.
Please Select
Postmenopausal bleeding
Unscheduled bleeding in postmenopausal women is abnormal and may indicate the
presence of endometrial cancer.
Nearly all cases of endometrial cancer (96%) are associated with a thickened
endometrium (>4 mm in postmenopausal women), which can be measured by
transvaginal ultrasonography. If the scan shows a thickened endometrium >4 mm, then
histological sampling is essential in the diagnostic evaluation of abnormal bleeding in
postmenopausal women.
Hysteroscopy combined with endometrial biopsy improves the detection of intrauterine
pathology and has a high specificity (highly unlikely not to detect cancer). SIS is a
sensitive technique for the detection of intrauterine, intramural and ovarian pathology
but does not provide histological data.
Causes of vaginal bleeding in postmenopausal women
Polyps
30%
Submucosal fibroids
20%
Endometrial atrophy
30%
Hyperplasia
815%
Endometrial carcinoma
810%
2%
24
Tamoxifen usage, like HRT, also increases the risk of developing endometrial
hyperplasia or cancer, but TVUS can be misleading in these patients.
Tamoxifen can cause subendometrial cyst development, which makes the endometrium
appear thickened in transvaginal sonograms. However, the subendometrial cystic
tissue can be differentiated from the endometrium itself in SIS.
Endometrial thickness
The thickness of the endometrial stripe can be measured accurately by transvaginal
sonography and it has been estimated that 96% of postmenopausal women with
endometrial cancer will have an endometrial thickness (ET) >4 mm. At this threshold,
the false positive rate is 50%.
Women with PMB whose ET is <4 mm still have a 12% risk of having endometrial
cancer. TVUS can also show if the endometrial lining is very thin. If so, the bleeding
may be due to endometrial atrophy.
It has, therefore, been suggested that as a minimum screening test an endometrial
biopsy is required if ET is:
25
Endometrial cancer
The preferred investigation of endometrial cancer is hysteroscopy and either blind
endometrial biopsy (using Pipelle sampler) or hysteroscopic-guided endometrial biopsy.
This diagnostic test may be expanded in a 'therapeutic manner' by performing
hysteroscopic resection of any identified intrauterine focal lesions (polyps, submucous
fibroids), i.e. see-and-treat.
This test has a 99% specificity in women with PMB.
If this test is negative, then endometrial cancer is highly unlikely as the post-test
probability of endometrial cancer is <0.5%.
Predictive values for endometrial cancer in postmenopausal women
Sensitivity
Specificity
PPV
NPV
67%
56%
7%
97%
87%
98.5%
82%
99.1%
SIS
89%
46%
16%
97%
86%
99.2%
100%
99.5%
Case study
A 56-year-old woman presents with two episodes of PMB. She has taken continuous
combined HRT for the last 3 years. Her last cervical smear was 2 years ago and was
normal.
Below is an image of her transvaginal pelvic ultrasound investigation, which shows her
endometrial thickness being 14 mm (1.48 cm).
26
Based on the patient history and investigations, what assessments would you
perform next?
Write your answer in the reflective notes before proceeding to the next page.
Assessment
The following key assessments follow a investigation of the woman's clinical history:
o
o
Average score:
0%
detectable by SIS
True
False
SIS is more sensitive than TVUS for detecting focal abnormalities of the
endometrium
True
False
Intermenstrual bleeding
Intermenstrual bleeding (IMB) encompasses any bleeding which occurs outside of the
womans menstrual period. It may affect between 1321% of women. The incidence in
perimenopausal women is as high as 24%. IMB can also include postcoital bleeding. It is
a symptom which although largely attributed to a benign cause, can result in significant
distress to the patient as it is a commonly known and accepted symptom of cervical
cancer.
28
Causes
Causes of IMB can be classified based on their anatomical site. Commencing at the top
of the reproductive tract they are:
o
o
o
o
o
o
o
o
29
Cervical cytology with high vaginal and endocervical swabs should be obtained for the
diagnosis of STIs. See the StratOG core training tutorial on Sexually transmitted
infections (including HIV) for detailed information on the investigation and
management of STIs.
Causes
Investigation
Treatment
Infection
Endometritis
Cervicitis
Vulvovaginitis
Bacterial/viral
swabs +/imaging
Appropriate
antibiotics/antivirals/antifungals
Iatrogenic
Breakthrough bleeding
Secondary to
examination/smear test.
As clinically
indicated
Alternating dosage/type of
hormone administered +/tranexamic acid
Structural (benign)
Uterine/cervical
polyps/fibroids
Ectropion
Vaginal adenosis
Radiological
imaging +/hysteroscopy
Structural
(premalignant/malignant)
Uterine/cervical/vaginal/v
ulval cancer
CIN/VaiN/VIN
Ovarian estrogen
secreting tumors
In accordance
with local and
national
protocols
Natural
If clinically
12% of women will have indicated
midcycle spotting, associated
with ovulation
Reassurance
(COC). She has been taking a COC for 6 years. Her last cervical smear (performed 3
months ago) was normal, as was her clinical pelvic examination.
The consultant refers the woman to secondary care and a transvaginal pelvic
ultrasound is requested.
uterine cavity 7 cm
normal ovaries (left 2 cm, right 3 cm with follicle)
thickened endometrium (12 mm) with a prominent endometrial echo (25 mm by
20 mm) indicating a possible polyp.
The following management options are considered:
Option 1: saline infusion sonography.
Option 2: outpatient diagnostic hysteroscopy.
Option 1: saline infusion sonography
31
An intrauterine polyp (3 x 2 cm) located at the fundus was identified through outpatient
diagnostic hysteroscopy.
Based on the patient history and investigations, what treatment option would
you suggest?
Write your answer in the reflective notes before proceeding to the next page.
IMB case study answer
Based on the patient history and investigations, what treatment option
would you suggest?
Answer: Hysteroscopic resection is a highly effective therapeutic option. The polyp in
this case was resected hysteroscopically in the outpatient setting using Versapoint.
Key points
Uterine polyps, whether endometrial or submucous fibroid polyps, are a
common cause of intermenstrual bleeding (IMB).
Once diagnosed by hysteroscopy, uterine polyps are easily treated by
hysteroscopic techniques with highly successful results in the vast majority of women.
1477756374
frmReflectiveNote
Causes of IMB
32
Assessment history:
Score
Total attempts:
Average score:
0%
Endometrial polyp
True
False
HRT
True
False
Intrauterine device
True
False
Etonogestrel implant
33
True
False
No effect
Decrease 3050%
No effect
Decrease 2040%
No effect
Combined oral
No data
contraceptive (synthetic
estrogen)
Decrease 40%
Licensed
contraceptive
Combined oral
contraceptive Qlaira
Decrease 30%
Licensed
contraceptive
No data
34
(natural estrogen)
Oral progestogen (high- No effect
dose)
Decrease 60%
Contraceptive effect
or licensed
contraception
Intrauterine
progestogen (LNG-IUS)
Decrease 30%
Decrease 70100%
(may also treat
endometriosis and
adenomyosis)
Licensed
contraceptive
Decrease 30%
Progestogen-only
implant (Nexplanon) or
Progestogen-only
injectable
(Depoprovera)
Unknown
Excision and
removal of
intracavitary
fibroids
Decrease 5080%
Improved if excising
submucous fibroid
No effect if excising
uterine polyp
Endometrial ablation
No effect
Transcervical resection
of endometrium
Will be able to
Decrease 80%-100% Likely contraceptive
excise and
but contraception is
removal
advised following
intracavity fibroids
ablation
Laparoscopic
myomectomy
Decrease 50%
Treatment still
under trial
Decrease 6080%
Decrease 30%
35
improve fertility
Laparoscopic uterine
Decrease 20-30%
artery occlusion (with or
without ovarian artery
occlusion)
Decrease 50%-60%
Treatment still
under trial
Doppler-guided
transvaginal uterine
artery occlusion
Decrease 40-60%
Treatment still
under trial
Decrease 20-30%
Improved,
particularly if
uterine cavity is no
longer distorted
Hysterectomy
Complete cure
Irreversible
contraceptive
Complete cure
National Institute for Health and Clinical Excellence. Heavy menstrual bleeding. CG44.
London: NICE; 2007.
National Institute for Health and Clinical Excellence. Heavy menstrual bleeding: quick
reference guide. CG44. London: NICE; 2007.
Gupta J, Kai J, Middleton L, Pattison H, Gray R, Daniels J, et al. Levonorgestrel
intrauterine system versus medical therapy for menorrhagia. N Engl J Med
2013;368:128-37.
NICE guidelines for HMB treatment
First-step medical treatment
For NICE first-step medical treatments for HMB, see Table 1 'Pharmaceutical treatments
proven to reduce menstrual bleeding' on page 7 of the NICE quick reference guide,
CG44 (to change the view of a pdf, you can right-click and select 'Rotate Clockwise', or
select the options in the Adobe menu, 'View/Rotate View/Clockwise').
Second- and third-step medical treatment
For NICE second- and third-step treatments for HMB, see Table 2, 'Surgical and
radiological treatment options for women whose quality of life is severely impacted' on
page 89 of the NICE quick reference guide, CG44.
National Institute for Health and Clinical Excellence. Heavy menstrual bleeding: quick
reference guide. CG44. London: NICE; 2007.
36
Dysmenorrhoea
Menorrhagia-DUB
Endometriosis, adenomyosis
Endometrial hyperplasia
32% had
hysterectomy
37
At 5 years
Costbenefit
analysis:
1477756708
42% had
hysterectomy
frmReflectiveNote
39
40
any sounding or dilation of the cervix has not caused a perforation or false
passage, resulting in subsequent introduction of the ablation device into the wrong
space
the operator can accurately determine uterine cavity length (and cervical canal
length if using NovaSure).
1.
Endometrial ablation
Assessment history:
Score
Total attempts:
Average score:
0%
True
False
Hysterectomy
Vaginal hysterectomy
Individual patient assessment is essential when deciding the route of hysterectomy,
and the following factors need to be taken into account:
to the woman provided she has been informed of the alternatives and their
risks/benefits.
Abdominal hysterectomy
Preoperative GnRHa treatment for 34 months may facilitate surgery by reducing
preoperative anaemia, intraoperative blood loss and the need for transfusion. Studies
have shown a reduction of fibroid size of by 60%, which may enable a lower transverse
incision (lower morbidity) rather than vertical midline laparotomy incision (higher
morbidity) when conducting the abdominal hysterectomy.
Indications
Hysterectomy should be only considered where:
After STH, there is a 27% risk of persisting cyclical bleeding, 2% risk of cervical
prolapse and a 1% risk of cervical cancer.
There is no difference between STH and AH in terms of quality of life,
constipation, prolapse, satisfaction with sex life, pelvic pain, vaginal bleeding or
complication rates.
43
The decision about the appropriate route for hysterectomy depends on:
AH
VH
Death
4.5%
5% to +20%*
Severe nocturia*
5% to +10%*
Blood transfusion
34%*
Bowel injury
0.7%
4.3%
<0.01
0.2%
44
%
Vascular injury
0.8%
0.9%
1.8%
Pelvic haematoma
46%
46%
46%
2%
2%
4%
7%
0%
2%
Conversion to laparotomy
NA
3%
4%
1.6%
2.3%
Bleeding
1.6%
<0.01
%
0.4%
UTI
5%
1.3%
5%
Chest infection
5%
7%
0.6%
13%
7%
10%
Venous thromboembolism
<0.01
%
<0.01
%
0.6%
Hysterectomy
Assessment history:
Score
Total attempts:
Average score:
0%
45
False
There are fewer abdominal wall infections and other postoperative infective
episodes for LH versus AH
True
False
In women undergoing VH compared with AH, hospital stay was shorter and
there was a quicker return to normal activities
True
False
46
True
False
Over the short- and long-term, there is higher patient satisfaction with
hysterectomy than endometrial ablation
True
False
Key points
Utilise the NICE 2007 Heavy menstrual bleeding guideline with its three-step
approach.
Step one is medical treatment with both hormonal and non-hormonal treatment.
Step two is minimally invasive uterus conserving surgery e.g. hysteroscopic
fibroid resection, endometrial ablation, transcervical resection of endometrium and
laparoscopic myomectomy.
Additional treatments have been added to step 2 involving newly developed
intervention in keeping with the above. It includes MRI guided focused USS therapy,
radiofrequency ablation of fibroids, uterine fibroid embolisation and laparoscopic
uterine artery occlusion.
Step three involves major surgical procedures e.g. abdominal myomectomy and
hysterectomy.
1477757342
frmReflectiveNote
Treatment of HMB
47
Assessment history:
Score
Total attempts:
Average score:
0%
Choose the treatment technique associated with the adverse effects listed in the items
below. Each option can be used once, more than once or not at all.
A: Tranexamic acid
B: Uterine artery embolisation (UAE)
C: Myomectomy
D: Non-steroidal anti-inflammatory drugs
E: Combined oral contraceptives
F: Hysterectomy
G: GnRHa (gonadotrophin-releasing hormone analogue)
H: Injected long-acting progestogens
I: Oral progestogen: norethisterone (15 mg) daily
J: Endometrial ablation
K: Oophorectomy at time of hysterectomy
L: Mirena (levonorgestrel-releasing intrauterine system)
Licensed for 5-year therapeutic usage. COMMON: irregular bleeding that may
last for over 6 months, hormone-related problems such as breast
tenderness, acne or headaches (generally minor and transient). LESS
COMMON: amenorrhoea. RARE: uterine perforation at the time of device
insertion.
Please Select
Only taken at the time of menses, no hormonal side effects, noncontraceptive. LESS COMMON: indigestion, diarrhoea, headaches.
Please Select
Only taken at the time of menses, no hormonal side effects, noncontraceptive. COMMON: indigestion; diarrhoea. RARE: worsening of asthma
in sensitive individuals, peptic ulcers with possible bleeding and peritonitis.
Please Select
Taken daily from days 526. COMMON: hormonal side effects, weight gain,
bloating, breast tenderness, headaches, acne (but all are usually minor and
transient) RARE: depression.
Please Select
Preparations are licensed for 4 weeks or 3 months. COMMON: menopausallike symptoms (such as hot flushes, increased sweating, vaginal dryness)
which may require add-back therapy. LESS COMMON: osteoporosis,
particularly trabecular bone with longer than 6 months' use.
Please Select
Day-case procedure. COMMON: persistent vaginal discharge, postembolisation syndrome [pain, nausea, vomiting and fever (not involving
hospitalisation)]. LESS COMMON: need for additional surgery, premature
ovarian failure particularly in women over the age of 45 years, haematoma.
RARE: haemorrhage, non-target embolisation causing tissue necrosis,
infection causing septicaemia.
Please Select
Average score:
0%
The following items are clinical scenarios of women presenting with abnormal uterine
bleeding. For each item choose the best diagnostic procedure from the options listed
above that enables optimal management. Each option can be used once, more than
once or not at all.
A 61-year-old woman is concerned because over the last week she has been
experiencing vaginal blood loss described as a period-like. Her final
menstrual period was when she was around 50 and she has never taken HRT.
Please Select
Asymptomatic
Heavy menstrual bleeding
51
Postmenopausal bleeding
Prolapse through cervical ostium
Abnormal vaginal discharge
Breakthrough bleeding
Infertility:
large or multiple endometrial polyps can contribute to miscarriage and
infertility. Evidence also suggests that a polypectomy may improve spontaneous
conception rates in women with an endometrial polyp as the only factor contributing to
subfertility by normalising endometrial implantation factors
Malignancy
polyp size of >1 cm, abnormal uterine bleeding and postmenopausal
status are all independent risk factors for malignant polyps. Hysteroscopic markers for
malignant endometrial polyps include surface irregularities such as necrosis, vascular
irregularities and whitish thickened areas, which are indications for obtaining a
histological diagnosis.
Diagnostic modalities
Pelvic ultrasound
Saline infusion sonogram (SIS) safe, well tolerated, rapid, minimally invasive,
highly sensitive and superior to ultrasound in diagnosing polyps
Hysteroscopy gold standard. Can be used to see and treat at the same sitting.
Enlarge
52
Enlarge
Management
o
o
o
Hysteroscopic Polypectomy:
symptomatic polyps
asymptomatic polyps in postmenopausal women irrespective of size
asymptomatic polyps in premenopausal women >1 cm in size.
Observational treatment:
asymptomatic polyps in premenopausal women 1 cm in size.
Annan JJ, Aquilina J, Ball E. The management of endometrial polyps in the 21st Century.
The Obstetrician & Gynaecologist 2012;14:3338.
Key points
Endometrial polyps are localised hyperplastic overgrowths of endometrial glands
and stroma.
They can cause HMB, PMB, abnormal vaginal discharge and breakthrough
bleeding. When large or multiple they are implicated in subfertility.
Polyps of >1 cm, AUB and PBM are all risk factors for malignant polyps.
Diagnosis is achieved with USS, SIS and hysteroscopy.
They can be observed or removed hysteroscopically (symptomatic,
asymptomatic in postmenopausal patient, >1cm in size in an asymptomatic
premenopausal patient).
Adenomyosis
Background
53
54
There are few randomised controlled trials assessing the effectiveness of treatment in
women with adenomyosis given the difficulties in accurate clinical diagnosis.
Nonetheless, there are varying levels of evidence to support the following treatments.
o
o
o
o
o
o
o
Medical:
nonhormonal therapy, including mefenamic and tranexamic acid, may be
effective for the symptomatic relief of menorrhagia
low-dose, continuous combined oral contraceptives with withdrawal bleeds
every 4-6 months may be effective in relieving menorrhagia and dysmenorrhea
high-dose continuous daily oral progestogens
GnRHa agonist
Mirena LNG-IUS.
Uterus conserving:
balloon endometrial ablation
uterus-conserving minimally invasive treatments: uterine artery
embolisation, MRgFUS.
Adenomyoma excision at the time of abdominal myomectomy.
Laparoscopic myometrial electrocoagulation induces localised coagulation and
necrosis of adenomyosis uteri. This technique may be used in women > 40 years of age
who have completed their families, but who wish to avoid hysterectomy. Risks include
adhesion formation, bleeding resulting in a hysterectomy and difficulty in precise
application resulting in the weakening of the remainder of the myometrial tissue.
Hysterectomy.
New treatments for adenomyosis being trialled include: aromatase inhibitors, selective
progesterone receptor modulators (e.g. asoprisnil) and bipolar radiofrequency ablation
via hysteroscopy or laparoscopy.
Imaging
Pelvic ultrasound imaging
55
Enlarge
MRI imaging
Key points
A benign condition causing heavy painful periods, contributing to 10% of HMB
and 30% of HMB with dysmenorrhoea.
Histologically it is defined as the presence of non-neoplastic endometrial glands
and stroma in the myometrium.
On USS it is represented by an enlarged globular regular uterus with no fibroids,
myometrial cystic areas and decreased myometrial echogenicity.
MRI diagnostic rates are higher than USS.
There are no serum markers available.
Management options include:
medical mefanamic, tranexamic acid, low dose COC, high dose
continuous progesterones, GnRHa agonists and the Mirena LNG-IUS
uterus conserving balloon ablation and uterine artery embolisation
adenomyoma excision at abdominal myomectomy
laparoscopic myometrial electrocoagulation
hysterectomy.
Leiomyoma (fibroids)
56
Uterine fibroids
Uterine fibroids are smooth muscle tumours of the uterus. While they are generally
benign, occasionally (<1%) malignant transformations can occur (leiomyosarcoma).
Uterine fibroids are generally age-related and are a commonly occurring pathology.
They are more common in African-Caribbean women than any other ethnicity. They
vary tremendously in size from millimetres to tens of centimetres and are associated
with heavy periods, pressure symptoms and occasionally pain.
Fibroids are responsive to the female hormones (estrogen and progesterone), generally
shrinking to a degree at menopause. They are classified as subserosal, intramural and
submucous according to their uterine location (see image below).
Site, size and number of fibroids are linked to the level of MBL.
57
Enlarge
58
59
The NICE guideline for HMB (2007) has indicated that when surgery is necessary for
fibroid-related HMB, then the clinical case notes must demonstrate that there has been
due discussion and documentation of all treatment alternatives.
Issues like risk of re-treatment are significant for all uterus-conserving treatments;
around 20%30% of all second-step treatments and abdominal myomectomy require
re-treatment in 2 years due to fibroid regrowth.
Treatment hierarchy
Seeking contraception
Wishing to
conceive
First step
COCs
Oral progestogens
Injected progestogens
Mirena LNG-IUS
Short (<6 month) course of
GnRHa
Tranexamic acid
NSAIDs
Second step
Third step
Abdominal
myomectomy
All focal fibroid treatments in RED font, Global uterine treatments in BLACK font
Preoperative GnRHa
There is evidence to support the use of a 34 month course of GnRHa prior to
myomectomy/hysterectomy as pre-treatment, as it:
symptoms are: severe (HMB, pressure-like effects, pain), there is significant pathology
(>20 week sized multifibroid uterus) that is unlikely to respond to other treatments;
there is a patient preference for definitive treatment and future fertility is not desired.
Another justification for hysterectomy is the combination of age and a significantly
pathological fibroid uterus. Abdominal myomectomy in a woman over 41 years with a
>20w sized multifibroid uterus is unlikely to substantially improve fertility (although it
would alleviate HMB and pain symptoms to some extent) irrespective of whether IVF is
undertaken.
Therefore, careful consideration should be given to hysterectomy as the preferred
treatment option in such circumstances as it carries lower surgical risks than abdominal
myomectomy and will achieve definitive symptom cure. For women below the age of
41, it would be justifiable to perform an abdominal myomectomy for either fertility
improvement (if that was desired) and/or alleviation of fibroid symptoms (HMB, pain),
or both, if the woman desired to preserve her uterus and rejected minimally invasive
uterus-conserving treatment alternatives.
Myomectomy and fertility
There is considerable debate on whether myomectomy improves fertility, although it is
established that fibroid presence (submucous and intramural) are associated with
adverse fertility and pregnancy outcomes. Based on the limited robust data available,
systematic reviews have concluded:
61
National Institute for Health and Clinical Excellence. Heavy menstrual bleeding. NICE
clinical guideline 44. London: NICE; 2007.
Pretreatment
Ulipristal acetate (UPA) has been used predominantly in the context of managing HMB
in association with uterine fibroids. Ulipristal acetate is a selective progesterone
receptor modulator (SPRM), an orally active steroid compound, which reversibly blocks
the progesterone receptor in the endometrium and myometrium. The net effect is
inhibition of ovulation without significant effects on estradiol levels or glucocorticoid
activity.
UPA has been compared to treatment with a placebo (PEARL I), and leuprolide acetate
([3.75 mg 4 weekly] PEARL II) in the treatment of women with uterine fibroid associated
HMB. These studies have shown UPA to be effective in controlling uterine bleeding
related to myomas, reducing myoma size and having a good safety profile in the short
term. UPA was also found to be non-inferior to once monthly leuprolide acetate in
controlling uterine bleeding and was significantly less likely to cause hot flushes.
In clinical studies, SPRM administration has been associated with a pattern of benign,
nonphysiological, nonproliferative, histologic features of the endometrium termed P
receptor modulator associated endometrial changes (PAEC). This is entirely reversible
on stopping treatment.
In the UK, UPA is used in a dose of 5 mg once daily for up to 3 months for either
preoperative or intermittent treatment of moderate to severe symptoms of uterine
fibroids in adult women of reproductive age. Re-treatment should commence only when
menstruation has occurred. Repeated intermittent treatment has been studied up to 4
intermittent courses.
Donnez J, Tomaszewski J, Vzquez F, Bouchard P, Lemieszczuk B, Bar F, et al; PEARL II
Study Group. Ulipristal acetate versus leuprolide acetate for uterine fibroids. N Engl J
Med. 2012;366:42132.
Donnez J, Tatarchuk TF, Bouchard P, Puscasiu L, Zakharenko NF, Ivanova T, et al;
PEARL I Study Group. Ulipristal acetate versus placebo for fibroid treatment before
surgery. N Engl J Med. 2012;366:40920.
Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J, et al. Long-term medical
management of uterine fibroids with ulipristal acetate. Fertil Steril. 2016;105:165173.
Hysteroscopic myomectomy
Submucous fibroid classification (ESGE)
Type
Intramural extension
None
62
<50%
>50%
HMB
Decrease >80%
Fertility
Increase 4060%
12%
Uterine perforation
Sepsis; intrauterine adhesions
Haemorrhage
Additional treatment
Enlarge
Performing a hysteroscopic myomectomy using the hysteroscopic
resectoscope
63
64
The figure above shows a chronological sequence of photos taking from an abdominal
myomectomy procedure. Notice the use of a Foley catheter as a tourniquet around the
utero-upper cervix junction to create an avascular uterine body and therefore dry
myomectomy.
Abdominal myomectomy
Enlarge
Uterine artery embolisation (UAE) is an interventional radiological procedure where
both uterine arteries are blocked with particles injected via the femoral and uterine
arteries (see figure above). This causes the fibroids to shrink (necrosis due to vascular
occlusion) and is believed to have no permanent effect on the rest of the uterus.
Before performing the UAE treatment, ultrasound (ideally MRI) must be performed to
accurately measure and locate the fibroids, and to evaluate whether UAE is appropriate
for the woman. Interventional radiologists prefer to use MRI prior to UAE, to screen for
pedunculated/part pedunculated fibroid lesions (FIGO L0-L2, and, L6-L7), which carry
attendant risks of sloughing tumour into uterine/abdominal cavities and/or pelvic sepsis
following the procedure. Hysteroscopy and endometrial biopsy is also advised to rule
out submucosal fibroids and ensure benign endometrium.
Contraindications
Pedunculated myomas
Recent GnRHa
Previous UAE
Postmenopausal status.
Procedure
A UAE is performed under conscious sedation with a local anesthetic at the site of
vascular catheterisation.
Effect on HMB
UAE alleviates symptoms of HMB in 7993% of treated women. Additionally, women
treated with UAE have reported significant beneficial effects within 3 months of the
procedure.
UAE remains effective in reducing HMB and pressure-like symptoms for up to 5 years,
although recent studies have shown that there is a 2029% chance of re-operation for
leiomyoma-related symptoms by this 5-year follow up.
Effect on fertility
The effect on fertility following UAE is unclear. There are no prospective studies
assessing fertility as a main outcome measure. Even so, there are at present around
100 cases of successful pregnancy (planned and unplanned) and live birth following
UAE.
Risks and/or adverse outcomes
Severe pain
Bleeding from puncture site
Anaphylactic reactions to contrast dye
Uterine endometritis, pelvic abscess, with or without infective sequelae
Precipitate menopause (28% risk)
Expulsion of necrotic fibroids or vaginal discharge (58% of cases) is more
common if fibroids are submucosal - this discharge may be unpleasant, prolonged and
distressing for the patient
Unable to confidently exclude leiomyosarcoma presence, although follow-up
interval imaging may show irregular, persisting residual tissue mass even after a
technically successful procedure.
The future
Further studies (with longer term follow up) are needed to evaluate the effectiveness
and safety of UAE compared with myomectomy / hysterectomy (and other techniques
such as radiofrequency ablation).
X-ray fluoroscopy imaging
67
68
Complications of UAE are based primarily on observational studies and data obtained
from various registries. These are divided into 3 major groups.
Immediate complications (<24 hours post procedure)
Local complications including pain, groin hematomas, contrast reactions and vasovagal
syncope have been reported. Non-target pelvic organ embolisation and pulmonary
embolism may occur.
Subacute complications (<30 days post procedure)
Post embolisation syndrome is a well-described phenomenon consisting of pain, fever,
nausea, leucocytosis and occasional malaise. It is a fairly common complication
associated with UAE and often needs to be distinguished from infections associated
with UAE. Treatment is supportive with analgesics, antipyretics, adequate hydration and
VTE prophylaxis. MRI may be needed in women with a protracted course of events to
rule out tissue necrosis and infection.
Infection (endometritis and sepsis) are rare complications associated with UAE. Uterine
necrosis is a rare complication, however, superimposed infection can be life
threatening. An MRI is prudent to help with the diagnosis. Most infections can be
managed with IV antibiotics and supportive treatment, although occasionally a
hysterectomy may be used in women with sepsis refractory to other measures.
Chronic complications (>30 days post procedure)
Fibroid expulsion is reported usually when UAE is used to treat submucous fibroids. A
partially attached and infarcted fibroid could require a further hysteroscopic resection.
Chronic vaginal discharge has been reported.
Non-target embolisation usually affects the ovaries and occasionally the vagina. When
the vaginal blood supply is compromised, the resultant vagina ischemia could result in
sexual dysfunction/dyspareunia. When the uteroovarian blood supply is affected, the
resultant ovarian ischemia is associated with follicular depletion and premature
menopause in older women (>45 years). In younger women, transient postmenopausal
symptoms have been reported. A high FSH level usually reverts to normal in 1012
months. The potential for compromising fertility does exist and as such UAE is a
relatively contraindication in women wishing to retain their fertility.
Risk of miscarriage
UAE is associated with a higher cumulative risk of miscarriage; several fold higher than
the general population. Possible explanations include endometrial ischemia resulting in
an altered environment for implantation and fibroid migration and distortion of the
endometrial contour.
MRI-guided focused ultrasound ablation of uterine fibroids
69
20% at 2 years
AUB
6070%
Higher NPV corresponds to greater fibroid size reduction and symptom relief at 12
months
Fertility
Secondary treatment
? 30%
Complication rate
1477769200
frmReflectiveNote
Key points
Fibroids are smooth muscle tumours of the uterus, usually benign but they can
have malignant transformations in >1% resulting in leiomyosarcoma.
They are classified by their location as subserosal, intramural and submucous.
Symptoms include AUB, HMB, dysparunia, anaemia and pressure symptoms. In
obstetrics they can cause subfertility, miscarriage, pain secondary to degeneration,
preterm labour, malpresentation and postpartum haemorrhage.
Treatment options vary depending on whether the woman wishes to conceive or
not.
Seeking contraception:
1st step COC, oral/injected/IUS progestogens, short course of GnRHa
2nd step hysteroscopic myomectomy +/- ablation +/- Mirena IUS.
Additional minimally invasive uterus-conserving treatment; UAE, MR focused
ultrasonography, laparoscopic uterine artery occlusion and bipolar radiofrequency
ablation
3rd step hysterectomy +/- bilateral salpingo-ophrectomy.
Wishing to conceive:
1st step tranexamic acid/NSAIDs
2nd step hysteroscopic myomectomy, laparoscopic myomectomy.
Additional minimally invasive uterus-conserving treatments as above
3rd step abdominal myomectomy.
Leiomyoma (fibroid)
70
Assessment history:
Score
Total attempts:
Average score:
0%
Clinical scenario
A 38-year-old woman presents with a 2-year history of painful, heavy periods
She bleeds for 10 days each month
She feels her abdomen has become bloated over the same time period
She feels tired most of the time, especially at the time of menses
She has occasional constipation
She is parity 2
The GP has palpated a large, abdominal mass arising from the pelvis that feels
firm
71
True
False
Endometrial hyperplasia
Enlarge
Endometrial hyperplasia is defined as a proliferation of glands of irregular size and
shape with an increase in the glands/stroma ratio.
Endometrial hyperplasia is further classified into simple and complex hyperplasia based
on the complexity and crowding of the glandular framework:
Cytological and
architectural
criteria
Risk of
malignancy
if untreated
Risk of spontaneous
regression if untreated
13%
progression
90% spontaneous
regression rate
72
rate
Crowded or closely
opposed glands
15%
progression
rate
8090% spontaneous
regression rate
1025%
progression
rate
Simple atypical
3050%
progression
rate
Complex atypical
Complex nonatypical
Less than 2% of hyperplasias without atypia progress to carcinoma and the mean
duration of progression to carcinoma takes almost 10 years.
Atypical hyperplasia progresses to carcinoma in 23% of cases over a mean
duration of 4 years.
Importantly, endometrial cancer may co-exist in 3050% of atypical endometrial
hyperplasias.
Prevalence
Incidence of endometrial hyperplasia is age dependent. In women aged 40 years or
younger with AUB, only 1.3% were noted to have simple hyperplasia. The incidence
increases with age. In the postmenopausal age group with AUB, the incidence is 815%,
which includes cases of non-atypical and atypical hyperplasia.
Women with the following risk factors should have a comprehensive evaluation (pelvic
ultrasound and endometrial biopsy) if they present with AUB.
Risk factors for endometrial hyperplasia and malignant transformation of endometrial
hyperplasia include the following:
Treatment options
Remove any obvious exogenous estrogen sources. If taking oral or patch-based HRT,
then consideration could be given to Mirena LNG-IUS to both treat the endometrial
hyperplasia and continue to protect the uterus so that the patient can receive estrogen
only replacement therapy.
A similar approach could be used for tamoxifen-users, although Mirena-LNG IUS is only
licensed to be used as endometrial protection in HRT users and is not licensed for use in
tamoxifen users or women with endometrial hyperplasia.
Progestagens: oral progestagens (e.g. norethisterone) or Mirena LNG-IUS. Observational
studies have shown 9095% regression in non-atypical hyperplasias.
Atypical hyperplasia should be treated by hysterectomy, and bilateral
salpingoophorectomy if in the perimenopausal or postmenopausal age group. Highdose oral progestagens can be used for women deemed unfit for surgery.
Hysterectomy may be offered to non-atypical hyperplasia if they possess high risk
factors for malignant transformation (e.g. the patient is prescribed tamoxifen or has a
family history of endometrial cancer) or if they prefer this option to medical treatment
and interval endometrial surveillance.
In all cases of non-hysterectomy endometrial hyperplasia treatment, serial endometrial
biopsy surveillance should be instigated every 6 months (possibly every 3 months if
non-regressed hyperplasias). If there is non-regression or a persistence of non-atypical
hyperplasia beyond a defined interval (e.g. 6 or 12 months) or malignant
transformation (e.g. becomes atypical or endometrial cancer identified) then
hysterectomy and bilateral salpingoophorectomy should be performed.</
Tamoxifen and endometrial pathology
Women with breast cancer have an inherently increased risk of developing uterine
hyperplasia and uterine cancer irrespective of whether they are taking tamoxifen.
Around 1040% of women taking tamoxifen incur uterine abnormalities ranging from
unscheduled AUB, polyps, atypical hyperplasia and endometrial cancer. Pelvic scans
may identify the classical subendometrial cystic pathology and thickened endometrium
associated with tamoxifen users, which can be misinterpreted as invasive endometrial
cancer.
A randomised controlled trial showed that tamoxifen induces a two-fold increased risk
of endometrial cancer. The absolute risk for endometrial cancer in tamoxifen-treated
women was 13.0 per 1000 compared to 5.4 per 1000 in women taking placebo.
There appears to be no benefit in routinely performing pelvic ultrasound and
endometrial biopsy in asymptomatic tamoxifen users in order to detect underlying
endometrial hyperplasia or cancer. However, tamoxifen users with AUB should all
undergo comprehensive evaluation, including at least a pelvic ultrasound and
endometrial biopsy and preferably hysteroscopy.
74
Key facts
AUB is the most common presenting symptom of endometrial hyperplasia.
Endometrial hyperplasia, although a benign condition, may be considered as a
precursor to endometrial cancer.
It is most often diagnosed in postmenopausal women, but women at any age
with unopposed estrogen from any source are at an increased risk for developing
endometrial hyperplasia, e.g. HRT or tamoxifen.
In the absence of cytological atypia, less than 2% of cases progress to cancer.
In the presence of cytological atypia, around 3050% progress to endometrial
cancer or have co-existing endometrial cancer. Therefore, hysterectomy is
recommended for women with atypical endometrial hyperplasia.
Oral progestagens or Mirena LNG-IUS (unlicensed) have been used successfully
in the management of non-atypical endometrial hyperplasia.
The choice of treatment for endometrial hyperplasia is dependent on patient
age, the presence of cytologic atypia, the desire for future childbearing, and surgical
risk.
Endometrial hyperplasia
Assessment history:
Score
Total attempts:
Average score:
0%
Case scenario
75
76
Future trends
Reducing the need for hysterectomy: dilemma for healthcare provider,
clinician and woman
Hysterectomy exposes women to a risk (albeit low) of perioperative complications and
is therefore not considered an initial option, but as a third step option following
attempted treatment with either Mirena LNG-IUS or endometrial ablation (EA) or both.
Promoting LNG-IUS and endometrial ablation therapies will help reduce the need for
hysterectomy in women with HMB and represents cost-effective treatment on direct
head-to-head treatment analysis. Cost savings are further amplified if outpatient local
anaesthetic, rather than day-case general anaesthetic, endometrial ablations are
performed. Uterine fibroid embolisation is becoming established as a treatment for
multi-fibroid, uterus-related HMB and is being offered by more hospital centres.
However, this impetus has recently been challenged by a cost-effectiveness analysis of
meta-analysed individual patient data. Despite longer hospital stay and time to
resumption of normal activities, more women were satisfied after hysterectomy
than after EA. Mirena was cheaper and more effective than first-generation ablation
techniques, with rates of satisfaction that were similar to second-generation EA.
Although hysterectomy is more expensive, it produces more quality-adjusted life years
(QALYs) relative to other remaining strategies and is likely to be considered cost
effective. The incremental cost-effectiveness ratio for hysterectomy compared with
Mirena is 1440 (1633, $2350) per additional QALY. The incremental cost-effectiveness
ratio for hysterectomy compared with second-generation ablation is 970 per additional
QALY.
UKs Health Technology Assessment, that funded the research, recommended that
future research should focus on evaluation of the clinical effectiveness and cost
effectiveness of the best second-generation EA technique under local anaesthetic
versus Mirena and types of hysterectomy such as laparoscopic supracervical
hysterectomy versus conventional hysterectomy and second generation endometrial
ablation.
77
Roberts TE, Tsourapas A, Middleton LJ, Champaneria R, Daniels JP, Cooper KG, et al.
Hysterectomy, endometrial ablation, and levonorgestrel releasing intrauterine system
(Mirena) for treatment of heavy menstrual bleeding: cost effectiveness analysis. BMJ
2011;342:d2202.
Middleton LJ, Champaneria R, Daniels JP, Bhattacharya S, Cooper KG, Hilken NH, et al.
Hysterectomy, endometrial destruction, and levonorgestrel releasing intrauterine
system (Mirena) for heavy menstrual bleeding: systematic review and meta-analysis of
data from individual patients. BMJ 2010;341:c3929.
HMB
Fertility
Decrease 3040%
Decrease
Contraceptive
Decrease 40%
Decrease uterine
size 40%
Decrease (risk of
endometrial
hyperplasia)
Contraceptive
SPRMs:
Asoprisnil
Proellex
Decrease
Decrease
Contraceptive
SERM:
Ormeloxifene
Unknown
Decrease
Contraceptive
Aromatase
Inhibitor:
Anastrozole
Decrease
Decrease
Contraceptive
May decrease
Contraceptive
Combined pill:
Unknown
Dienogest combined
with estradiol
valerate (Qlaira)
Decrease
Contraceptive
GnRH antagonist:
Ganirelix
Progesterone
receptor
antagonist:
Mifepristone
Women treated with E2V/DNG have significantly shorter and lighter withdrawal
bleeding than women treated with an ethinylestradiol/levonorgestrel (EE/LNG) pill.
Around 20% of women on E2V/DNG reported absent withdrawal bleeding. Furthermore,
E2V/DNG has been shown to reduce menstrual bleeding in women with HMB. E2V/DNG
is the only oral contraceptive with a licensed indication for the management of heavy
menstrual bleeding.
Developing new surgical treatments for fibroids
consider examining in colposcopy suite for better patient positioning and lighting
probe the lower cervical canal to see if threads are visible. If so, grasp the thread
with polyp forceps
often the threads and/or inferior aspect of body of IUCD, are withdrawn into the
internal os/isthmic portion of uterus and may be retrieved using long fine artery forceps
or specific IUCD plastic retriever.
79
life
what are her treatment expectations, e.g. need for definitive treatment, wishes
to avoid any type of surgery, wishes to avoid surgery that has prolonged convalescence
because of work/home factors
shared decision making during counselling
aim to individualise information on risks and benefits of treatment
alternatives and document of this process
80
variety of techniques (TBEA, MEA, Novasure) with procedure times <15 mins
most can be performed in an outpatient setting, with or without local
anaesthetic, same day discharge, or as day case GA procedures
most women do not need endometrial thinning or menstrual phase timing
highly effective and safe (safer than previous first generation techniques)
short period of convalescence (12 weeks) compared with hysterectomy.
Disadvantages (compared with hysterectomy):
A 42-year-old woman is referred to you with a 4-year history of regular heavy periods
and pelvic pain. She is nulliparous.
The woman had been diagnosed to have a multi-fibroid uterus by another hospital and
has been recommended to have a hysterectomy. Abdominal examination reveals a 20w
sized fibroid uterus. She has been told that she has five fibroids, individually ranging in
size from 5 cm to 8 cm, at mostly intramural locations.
She is keen to preserve her uterus and wishes future fertility.
Outline your further investigations and justify your treatment options
accordingly.
Fibroid uterus case study answer
Outline your further investigations and justify your treatment options
accordingly.
Answer: This should include:
1. Baseline investigations in GOPD:
less than 1% chance of fertility, even if all fibroids are removed and IVF is
undertaken
is uterus preservation justified given such poor fertility prognosis and significant
uterine pathology and symptoms?
3. Realistic counselling about treatment option and individualised
risk/benefit:
83
A 55-year-old woman has been referred to the postmenopausal bleeding clinic following
an ultrasound organised by her GP for abdominal bloating. This showed the presence of
cystic spaces in the endometrium and an endometrial thickness of 15 mm. She has
previously used tamoxifen for 5 years for breast cancer.
What is the best management option?
High dose oral progestogens
Do nothing as she did not have any bleeding
Hysteroscopy and endometrial biopsy
Mirena IUS insertion
85
MRI
You review a 48-year-old woman in the menstrual disorders clinic who complains of a 3year history of heavy menstrual bleeding. She is a mother of four children, all born by
normal vaginal deliveries. Her menstrual cycle is every 29 days and the bleeding lasts
for 6 days. However, recently it has become associated with clots.
Cervical smears are up-to-date and her BMI is 39. You perform a transvaginal scan
which reveals a bulky uterus of 8 mm endometrial thickness and three intramural
fibroids of 2, 4 and 5 cm size respectively. On vaginal examination you find stage I
cystocele, stage II rectocele and stage II uterine descent.
The current waiting list for benign gynaecological surgery in your hospital is 4 months.
What is the next most appropriate step in her management?
Add on to the waiting list for laparoscopic-assisted vaginal hysterectomy
Arrange for pre-operative assessment for total abdominal hysterectomy
Counsel regarding NovaSure endometrial ablation
Insert Mirena intrauterine system and follow up in 6 months
Perform endometrial sampling
You are performing an outpatient hysteroscopy on a 62-year old woman who presents
with postmenopausal bleeding. Her menstrual cycles ceased at the age of 50. She used
combined HRT for 2 years afterwards.
A transvaginal scan reveals an endometrial thickness of 8 mm with a hyper-echoic
intracavitary shadow suggestive of an endometrial polyp. The size of the polyp was 16
mm in diameter.
What finding on hysteroscopy would make you consider the polyp as a
malignant lesion?
Broad-based avascular lesion
Haemorrhagic lesion with pus-like discharge
Multiple projections with mucous-like content
Smooth surface pedunculated polyp
Vascular surface
A 46-year-old para 2 who has completed her family presents with a history of painful
heavy menstrual bleeding in association with infrequent cycles (every 23 months) for
1 year. Her BMI is 44. She is currently on iron supplements for anaemia and is
prescribed proton pump inhibitors for GORD. She is otherwise fit and well.
Abdominopelvic examination is unremarkable. Pelvic ultrasound shows an endometrial
86
thickness of 12 mm with a bulky uterus and normal ovaries with no pelvic pathology. A
pipelle biopsy suggests a proliferative endometrium.
What treatment is most suited to her?
Combined oral contraceptive pill
GnRH Analogues
Mefenamic acid
Mirena IUS
Tranexemic acid
A woman who has recently had a uterine artery embolisation performed for a fibroid
uterus (18 weeks size intramural and submucous fibroids) presents to the emergency
department with fever, nausea, vomiting, and foul smelling vaginal discharge.
Which investigation is best suited to guide further management?
CT scan of the abdomen and pelvis
Hysteroscopy
MRI of the abdomen and pelvis
Transabdominal ultrasound
Transvaginal ultrasound
87