Abnormal uterine bleeding in fertile age Minimally invasive surgical solution

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1 Abnormal uterine bleeding in fertile age Minimally invasive surgical solution Professor Grigoris F. Grimbizis Head, 1 st Dept Obstet & Gynecol, Aristotle University of Thessaloniki ESGE Chair Elect

2 Declaration of Interests None (commercial) ESGE Chair Elect ESHRE Past Member of the Executive Committee Hellenic Society for Endoscopic Surgery Vice President

3 Abnormal Uterine Bleeding: Definition / Comments Abnormal Uterine Bleeding is defined as bleeding from the uterine corpus that is abnormal in volume, regularity and/ or timing with an estimated blood loss >80ml per period The term dysfunctional uterine bleeding is abandoned Life-time prevalence ~30% Substantial impact on women s physical, emotional, social and material quality of life Associated with loss of productivity, and major health care costs

4 Menstrual parameters Infrequen t (>38 days) Frequenc y (days) Normal (24-38 days) Frequent (<24 days) Absent (-) Regularit y (12 mo variaton) Regular (±2-20 days) Irregular (>20 days) Shortene d (<4,5 days) Duration (days) Normal (4,5-8,0 days) Prolonge d (>8 days) Light (<5ml) Volume (monthly / ml) Normal (5-80ml) Heavy (>80ml) Munro, Rev Endocr Metab Disorders, 13: , 2012

5 FIGO Classification of AUB Abnormal Uterine Bleeding (AUB) Acute Intermittent Chronic Polyp s PAL M Aden (Stru Leio omy ctura myo osis l) mas Mali gnan cy Coa gulo path y Ovul ator y COE IN End ome trial Iatr oge nic Not Clas sifie d

6 What is considered as minimally invasive surgery? Hysteroscopy Laparoscopy Diagnostic Diagnostic Operative Operative

7 Where is the place of minimally invasive surgery in the management of AUB? Management of AUB patient Confirmati on of AUB (based on symptoms) Diagnostic Work-up (etiological investigation) Treatment (based on diagnosis)

8 FIGO P(ALM)-Endometrial polyps Is hysteroscopic investigation necessary in cases of polyps? Is there a place for expectant management? When polyps size is <1cm When the diagnosis of polyp should not be considered as definite polypoid protrusions of the endometrium / hyperechoic endometrial areas Re-evaluation of symptoms and imaging findings after 3 menstruations natural curettage Why hysteroscopy? Rationale for hysteroscopic polypectomy Histology (malignancy, premalignant) Blind D&C, even under ultrasound control, no longer recommended (success <50% / traumatic for endometrium) See and treat Bleeding control (improvement % of cases)

9 Hysteroscopic investigation in cases of AUB & infertility Non-diagnostic findings Septum & polyps

10 Atypical polypoid adenomyoma Endometrial adenocarcinoma Atypical polypoid adenomyoma Endometrial adenocarcinoma Hysteroscopic findings

11 Atypical polypoid adenomyomas Ultrasound image No difference from endometrial polyps!!! Hysteroscopic view No clear difference from nonadenomyotic polyps!!!

12 Atypical polypoid adenomyomas: Risk of endometrial carcinoma 12 8,8% (12/136 cases) 8,8% (12/136 cases) 9 6,6% within the polyp 2,2% in the adjacent endometrium Endometrial Hyperplasia Endometrial Adenocarcinoma Heatley, Histopathology, 48: , 2006

13 FIGO PAL (M) - Malignancy / Premalignant conditions Sampling of endometrial tissue is an important approach in fertile age women with AUB Although endometrial malignancy is found rarely among fertile age women with AUB, it must be excluded prior to any surgical intervention Ambulatory hysteroscopy can diagnose diffuse or focal endometrial hyperplasia or malignancy and aid blind or directed Endometrial Biopsy Copper et al, 2015

14 Distribution of age in women with endometrial complex hyperplasia or cancer Age cut-off for biopsy was removed it is no longer relevant

15 Should diagnosis be based only in hysteroscopic findings without histological confirmation? Accuracy of hysteroscopy in the diagnosis of endometrial cancer and hyperplasia: a systematic review The pre-test probability of endometrial cancer was 3.9% (95% CI 3.7%-4.2%) A positive hysteroscopy result increased the probability of cancer to 71.8% (95% CI 67%-76.6%) A negative hysteroscopy result decreased the probability of cancer to 0.6% (95% CI 0.5%-0.8%) The overall accuracy for the diagnosis of endometrial disease was moderate compared to that of cancer Conclusion: hysteroscopic investigation should always be completed with guided histological examination Clark et al, JAMA, 288: 1610, 2002

16 Coa gul opa thy Ovu lato ry C O E I N End om etri al Iatr oge nic Not Clas sifie d Is there a place for minimally invasive (hysteroscopic) investigation?

endometrial layer Focally disordered proliferative endometrium Diagnostic

17 FIGO CO (E) IN Endometrial 41 years old - Heavy menstruation / spotting - No ultrasound findings Hysteroscopic currettage Removal of the functional endometrial layer Focally disordered proliferative endometrium Diagnostic hysteroscopy Adhesion (non-significant) / Normal appearing endometrium / protrusion?

18 FIGO COEI (N) Hysteroscopic images suggestive of adenomyosis

19 Confirmatio n of diagnosis Imaging AUB Patient: diagnosti c workup Findings needed histology No findings Is there a place for minimally invasive investigation? Hysteroscopy Leiomyomas Adenomyosis Iatrogenic (Niches) Polyps Suspected endometrial pathology Exclusion of endometrial pathology

20 Consider hysteroscopic guided endometrial biopsy NICE 2018 Persistent intermen strual bleeding Irregular uterine bleeding infrequen t heavy bleeding Heavy menstrual bleeding not respondin g to medicatio n Tamoxifen intake Obese (BMI>30) PCOS

21 Minimally invasive surgical solution in the treatment of AUB? Causativ e treatment Symptom atic treatment Minimally invasive / Invasive Medical / Non-surgical

22 FIGO P(ALM) - Polyps (atypical polypoid adenomyomas) Di Spiezio Sardo et al, Fertil Steril, 89:456, 2008 Initial Step Resection of polyp in healthy borders Pathology of the lesion!!! Resection of endometrium around the lesion Resection of myometrium under the lesion Multiple random biopsies of the endometrium

23 Recurrence rates after treatment of polypoid adenomyomas Pooled results of hysteroscopic and D&C treatment 40 Recurrence rates % 4/21 reported cases 37,5% 54/144 reported cases 0 Typical Polypoid Adenomyomas Mikos & Grimbizis, unpublished data, 2017

24 Recurrence rates of atypical polypoid adenomyomas Hysteroscopic vs D&C treatment 50 Recurrence rates 37, ,5 23,7 % 6/28 reported cases 41,4% 48/116 reported cases 0 Hysteroscopic Polypectomy Mikos & Grimbizis, unpublished data, 2014 D & C

25 FIGO (P) A (LM)-Adenomyosis Non-surgical medical and/or interventional Hormonal treatment: GnRH-a / LNG-IUS Uterine artery embolization Magnetic Resonance guided Focused Ultrasound Surgery (MRgFUS) Uterus sparing minimally invasive treatment Adenomyomectomy (laparoscopic or hysteroscopic) Thermal ablation of myometrium Endometrial ablation

26 FIGO (P) A (LM)-Adenomyosis Diffuse adenomyosis Medical treatment (LNG-IUD) Focal adenomyosis Minimally invasive surgical treatment (adenomyomectomy) Polypoid adenomyosis Minimally invasive surgical treatment (hysteroscopic)

27 FIGO (P) A (LM)-Adenomyosis Conservative excisional surgery Sub-serous layer 5 to 10mm could be usually preserved during lesion excision since it is rarely affected by the disease

28 Adenomyomectomy: post-operative results Reduction of pain and bleeding N=385 N=83 Reduc^on of Pain Reduc^on of Bleeding Grimbizis et al, Fertil Steril, 101: , 2014

29 FIGO (PA) L (M) - Leiomyomas Classical FIGO Submucosal: myomas that distort the uterine cavity Submucosal Type 0 100% intra-cavitary Type 0 Submucosal Type I >50% intra-cavitary Type 1 Submucosal Type II <50% intra-cavitary Type 2 Intramural: myomas within the myometrium that do not distort the uterine cavity Intramural In contact with the endometrium (JZ myomas) Type 3 Intramural 100% intramural Type 4 Intramural Intramural but <50% subserosal Type 5 Subserosal: myomas with >50% extension out of the serosal surface Subserosal Subserosal but <50% intramural Type 6 Subserosal Pedunculated Type 7

30 FIGO (PA) L (M) - Leiomyomas Hysteroscopic Myomectomy Abnormal Uterine Bleeding: + Submuco sal (FIGO Types 0,1&2) Abnormal Uterine Bleeding: +/- Intramur al (FIGO Types 3,4 & 2-5) Abnormal Uterine Bleeding: - Subseros al (FIGO Types 5,6,7) Laparoscopic Myomectomy Expectant management

31 FIGO COE (I) N Iatrogenic / Niches Hysteroscopic niche resection Laparoscopic niche repair Gubbini et al, JMIG, 18: , 2011 & van der Voet et al, BJOG, 121: , 2014

32 Is endometrial ablation / resection a minimally invasive solution? As Endometrial Ablation (EA) is characterized any method that destroys the lining of the uterine cavity (endometrium) It is a symptomatic surgical solution Target Control of Abnormal Uterine Bleeding (AUB) Minimally invasive alternative to: Medical management (if ineffective) Hysterectomy

33 First Generation: Hysteroscopic Techniques 1. Endometrial laser ablation 2. Trans-cervical resection of the endometrium 3. Endometrial rollerball Ablation

34 Second Generation: Non-Hysteroscopic Techniques 1. Fluid-filled thermal balloon endometrial ablation 2. Radiofrequency (thermo-regulated) balloon endometrial ablation 3. Hydrothermal endometrial ablation 4. Microwave EA (MEA) and impedancecontrolled bipolar radiofrequency ablation

35 Endometrial Ablation Efficacy: primary and secondary outcomes Post-ablation amenorrhea Range: 14-55% Post-ablation satisfaction rate The most important parameter because control of bleeding and not amenorrhea is the required effect

36 Un-satisfaction rates compared to hysterectomy 15 12, ,6 5 5,3 7% higher RR: 2.4 P< ,3% higher RR: 2.3 P< Hysterectomy 1st Generaron 2nd Generaron Un-Sa^sfac^on rates Battacharya et al, Health Technology Assessment 15: No. 19, 2011

37 Un-satisfaction rates compared to Mirena ,2 18, NS NS Mirena 1st Generaron 2nd Generaron Un-Sarsfacron rates Battacharya et al, Health Technology Assessment 15: No. 19, 2011

38 Endometrial Ablation Complications Fluid overload & Perforation (1 st generation Techniques) Infection: early (within 3 days) or late (up to 50 days) endometritis ( %) myometritis (0 0.9%) pelvic inflammatory disease (1.1%) Tubo-ovarian, pelvic and cornual abscess or pyometra (0 1.1%) / sepsis Prevention: antibiotic prophylaxis (although not routinely recommended) or therapy when suspected Treatment: hysterectomy and drainage Sharp, AJOG, 2012

39 Endometrial Ablation Complications: Post ablation pain syndrome Post-ablation pain syndrome (blood blocked within closed cavities) Contracture and scarring (due to tissue necrosis and nonmicrobial inflammation) in the presence of residual endometrium can result in obstructed egress of menses Manifested as hematocavities within the body of the uterine cavity (central hematometra) or at a cornual region Clinical symptom: cyclic or persistent pelvic pain Prevention: avoid destruction of cervical canal, partial ablation Treatment: hysterectomy or hysteroscopic adhesiolysis Sharp, AJOG, 2012

40 Abnormal Uterine Bleeding (AUB) Complications: Inefficient post-ablation sampling Inability to sample endometrial cavity in cases of recurrent bleeding could mask endometrial cancer Ablation does not increase the risk of endometrial cancer Absolute contra-indications: Endometrial hyperplasia an endometrial cancer Unknown importance of risk factors for cancer development Nulliparity & chronic anovulation Obesity & diabetes mellitus tamoxifen therapy hereditary non-polyposis colorectal cancer Sharp, AJOG, 2012

41 Incidence of endometrial cancer after endometrial ablation compared to that of general population Dood et al, J M I G, 2014

42 Endometrial Ablation Complication : Post-ablation pregnancy Wishing future fertility is a contra-indication for endometrial ablation Endometrial ablation could not be considered as a form of contraception Post-ablation pregnancies have higher risk for ectopic implantation (reported incidence 2-6%) miscarriages, Preterm delivery (~30%) and preterm premature rupture of membranes (~15%) Abnormal placentation / placenta accreta percreta (~25%) leading in obstetrical hysterectomy (~60%) Sharp, AJOG, 2012

43 Where is the place of minimally invasive surgery in the management of AUB? Confirmation of AUB (based on symptoms) Diagnostic Work-up (etiological investigation) Treatment (based on diagnosis) Hysteroscopic Evaluation Imaging findings needed histology Polyps Suspected endometrial pathology No findings Biopsy under vision

44 Where is the place of minimally invasive surgery in the management of AUB? Confirmation of AUB (based on symptoms) Diagnostic Work-up (etiological investigation) Treatment (based on diagnosis) Hysteroscopic treatment Polyps Leiomyomas (Type 0-2) Adenomyotic cysts No place for ablation Niches Laparoscopic treatment Leiomyomas Adenomyosis (mainly focal) Niches

46 THESSALONIKI - GREECE 6 TH -9 TH OCTOBER 2019 ESGE 28 TH ANNUAL CONGRESS

Medical Management of Fibroids Esmya. Dr Paula Briggs Consultant in Sexual and Reproductive Health

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