Heavy Menstrual Bleeding. Mr Nick Nicholas MD FRCOG Grad Dip Law. Consultant Gynaecologist

Transcription

1 Heavy Menstrual Bleeding Mr Nick Nicholas MD FRCOG Grad Dip Law. Consultant Gynaecologist

2 Why is HMB so important? 1:20 women aged consult their GP with HMB Once referred to gynaecologist, surgical intervention is highly likely 1in 5 women in UK will have hysterectomy before 60 In at least 50% of these,hmb will be the main problem In about 50% of all women who have a TAH for HMB they have a normal size uterus Only about 58% of women with HMB receive medical treatment prior to referral to a specialist NICE issued new guidelines in 2007

3 Incidence and Prevalence Affects approximately 880,000 women in England Annual rate of women with heavy menstrual bleeding presenting to services 6.00% 5.40% Rate of presentation 5.00% 4.00% 3.00% 2.00% 1.00% 0.67% 2.58% 1.94% 1.73% 2.10% 2.96% 4.47% 4.64% 0.00% 12 to to to to to to to to to 51 Age range

4 National RCOG Audit of HMB (2010) an Organisational audit of acute NHS trusts in England and Wales to describe the organisation of hospital gynaecological services, current referral patterns and local protocols with reference to the management of HMB a Prospective audit of patient-reported outcomes of women with HMB symptoms who attend outpatient gynaecology clinics between 1 February 2011 and 31 January 2012.

5 Relative rates of surgery for women with HMB in English PCTs between April 2006 and December 2009

6 Organisational audit of HMB n=221 NHS Hospitals 38.4% of responding hospitals reported that they had a dedicated menstrual bleeding clinic. The majority of hospitals reported the availability of ultrasound (80.0%), hysteroscopy (87.3%) and endometrial biopsy (97.7%) as well as a wide variety of surgical procedures and appropriate levels of investigations at the initial consultation.

7 Organisational audit of HMB 76.0% of hospitals provided an HMBspecific information leaflet for women, 8.3% referred women to a website for information and 19.8% did not provide written information. Only 29.9% of hospitals reported that they had a local, written protocol regarding the care and management of women with HMB.

8 Description of local HMB protocols Local HMB Guideline No of hospitals (214) % RCOG Standards NICE Care pathway protocol Locally developed protocol Reported having one but no proof No protocol

9 Management of HMB in Primary Care Taken from NICE Guideline Heavy Menstrual Bleeding January 2007

10 Risk factors for HMB Fibroids Polyps-do NOT cause HMB Blood Disorders Von Willebrands Disease Thyroid Disorders-NOT associated with HMB Endometriosis-usually causes pain but ALSO HMB

11 Risk factors for HMB Gynaecological conditions such as: uterine fibroids adenomyosis or endometriosis endometrial cancer unopposed oestrogen use Increase in age Ethnic group Sociocultural factors

12 Recommendations on definition of HMB For clinical purposes, HMB should be defined as excessive menstrual blood loss which interferes with the woman s physical, emotional, social and material quality of life, and which can occur alone or in combination with other symptoms. Any interventions should aim to improve quality of life measures. [D]

13 History taking for HMB Nature of bleeding Symptoms suggesting possible significant pathology ie pelvic pain and pressure symptoms To identify women s ideas, concerns, expectations and needs

14 Physical examination for HMB Physical examination of the woman by observation, abdominal palpation, visualisation of the cervix and bimanual (internal) examination has the purpose of detecting underlying pathology to inform treatment and the need for investigations

15 Recommendations on physical examination for HMB A physical examination should be carried out before all: LNG-IUS fittings investigations for structural abnormalities investigations for histological abnormalities. [D] Women with fibroids that are palpable abdominally or who have intra-cavity fibroids and/or whose uterine length as measured at ultrasound or hysteroscopy is greater than 12 cm should be offered immediate referral to a specialist.

16 Recommendations on laboratory tests for HMB A full blood count test should be carried out on all women with HMB. This should be done in parallel with any HMB treatment offered. [C] Testing for coagulation disorders (for example, von Willebrand disease) should be considered in women who have had HMB since menarche and have personal or family history suggesting a coagulation disorder. [C] A serum ferritin test should not routinely be carried out on women with HMB. [B] Female hormone testing should not be carried out on women with HMB. [C] Thyroid testing should only be carried out when other signs and symptoms of thyroid disease are present, otherwise DON T DO IT.[C]

17 Recommendations on investigations for HMB If appropriate, a biopsy should be taken to exclude endometrial cancer or atypical hyperplasia. Indications for a biopsy include, for example, persistent intermenstrual bleeding, and in women aged 45 and over treatment failure or ineffective treatment. [D] Imaging should be undertaken in the following circumstances: the uterus is palpable abdominally vaginal examination reveals a pelvic mass of uncertain origin pharmaceutical treatment fails. [D] Ultrasound is the first-line diagnostic tool for identifying structural abnormalities. [A]

18 Recommendations on investigations for HMB Hysteroscopy should be used as a diagnostic tool only when ultrasound results are inconclusive, for example, to determine the exact location of a fibroid or the exact nature of the abnormality. [A] If imaging shows the presence of uterine fibroids then appropriate treatment should be planned based on size, number and location of the fibroids. [D] Saline infusion sonography should not be used as a first-line diagnostic tool. [A] Magnetic resonance imaging (MRI) should not be used as a first-line diagnostic tool. [B] Dilatation and curettage alone should not be used as a diagnostic tool. [B] Where dilatation is required for non-hysteroscopic ablative procedures, hysteroscopy should be used immediately prior to the procedure to ensure correct placement of the device. [D]

19 Recommendations on education for women with HMB A woman with HMB referred to specialist care should be given information before her outpatient appointment. The Institute s information for patients ( Understanding NICE guidance Women should be made aware of the impact on fertility that any planned surgery or uterine artery embolisation (UAE) may have, and if a potential treatment (hysterectomy or ablation) involves the loss of fertility then opportunities for discussion should be made available. [D]

20 Intervention (LNG-IUS) Potential unwanted outcomes of interventions for HMB common = 1 in 100 chance, less common = 1 in 1000 chance, rare = 1 in chance, very rare = 1 in chance) Potential unwanted outcomes. Common: irregular bleeding that may last for over 6 months; hormone-related problems such as breast tenderness, acne or headaches, which, if present, are generally minor and transient Less common: amenorrhoea Rare: uterine perforation at the time of IUS insertion

21 Potential unwanted outcomes of interventions for HMB Intervention Tranexamic acid (NSAIDs) COCP Potential unwanted outcomes Less common: indigestion; diarrhoea; headaches Common: indigestion; diarrhoea Rare: worsening of asthma in sensitive individuals; peptic ulcers with possible bleeding and Peritonitis Common: mood changes; headaches; nausea; fluid retention; breast tenderness Rare: deep vein thrombosis; stroke; heart attacks

22 Potential unwanted outcomes of interventions for HMB Intervention Oral progestogen Injected progestogen Potential outcomes Common: weight gain; bloating; breast tenderness; headaches; acne (but all are usually minor and transient) Rare: depression Common: weight gain; irregular bleeding; amenorrhoea; premenstruallike syndrome (including bloating, fluid retention, breast tenderness)

23 Potential unwanted outcomes of interventions for HMB Intervention (GnRH-a Potential Outcomes Common: menopausal-like symptoms Less common: osteoporosis, with longer than 6 months use Endometrial ablation Common: vaginal discharge; increased period pain or cramping (even if no further bleeding); need for additional surgery Less common: infection Rare: perforation

24 Potential unwanted outcomes of interventions for HMB Intervention Uterine artery embolisation Common: persistent vaginal discharge; post embolisation syndrome pain, nausea, vomiting and fever (not involving hospitalisation) Less common: need for additional surgery; premature ovarian failure, particularly in women over 45 years old; haematoma Rare: haemorrhage; non-target embolisation causing tissue necrosis; infection causing septicaemia

25 Potential unwanted outcomes of interventions for HMB Intervention Myomectomy Possible Outcomes Less common: adhesions (which may lead to pain and/or impaired fertility); need for additional surgery; recurrence of fibroids; perforation (hysteroscopic route); infection Rare: haemorrhage

26 Potential unwanted outcomes of interventions for HMB Intervention Hysterectomy Possible Outcomes Less common: intra-operative haemorrhage; damage to other abdominal organs, such as the urinary tract or bowel; urinary dysfunction frequent passing of urine and incontinence Rare: thrombosis (DVT and clot on the lung) Very rare: death (Complications are more likely when hysterectomy is performed in the presence of fibroids)

27 Pharmacological Treatments Mirena IUCD Tranexamic Acid 1gm qds NSAIDs (mefanamic acid 500mgs tds) COCP Norethisterone (15 mg) daily from days 5 to 26

28 Pharmacological Treatments Injected long-acting progestogens.?gnrh analogues for fibroids DO NOT USE Danazol for HMB Oral progestogens given during the luteal phase only should not be used for the treatment of HMB Etamsylate should not be used for the treatment of HMB

29 Available surgical options for women with HMB at NHS hospitals in England and Wales

30 Surgical Options Endometrial ablative techniques (where fertility is not necessary, but contraception still necessary) Thermachoice Novasure MEA TCRE Dilatation and curettage should not be used as a therapeutic treatment

31 Surgical Options UAE, myomectomy or hysterectomy should be considered in cases of HMB where large fibroids ( > 3 cm in diameter) May need GNRH analogue

32 Surgical Options Hysterectomy NOT first line treatment solely for HMB should be considered only when: other treatment options have failed, are contraindicated or are declined by the woman there is a wish for amenorrhoea the woman (who has been fully informed) requests it the woman no longer wishes to retain her uterus and fertility.

33 Number of surgical operations for women with HMB in English NHS trusts between 1 April 1997 and 31 December 2009

34 When to refer? Palpable abdominal fibroids Intracavity fibroids Bulky uterus Uterine length at USS or hysteroscopy >12cm Failed medical treatment for?3/12 If no response to drugs Pt requesting surgical Rx Severe anaemia Drugs contraindicated/not tolerated Diagnosis uncertain

35 Costs and savings Recommendations with significant resource impact Annual cost millions full blood count investigations 0.9 transvaginal ultrasound investigations 10.4 endometrial biopsy for suspected endometrial cancer -0.9 pharmaceutical treatments levonorgestrelreleasing intrauterine system -0.6 substitution of hysterectomy with endometrial ablation -1.2 Total net cost of implementing the HMB guideline 8.7

36 Implementation advice on improving education and information provision for women with HMB Choice of treatment Women s preferences and choices and individualised options Shared decision making when uncertain Allow time to decide Opportunity to reconsider Opportunity for second opinion Woman s right to chose which option

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39 Thank You

40 What this talk is about? National HMB Audit 2010 Organisational Management of HMB in Primary Care What to give? When to refer? Some Secondary Care considerations

41 Between 1997 and 2009, the rate of surgery decreased in women under 40 years of age, falling by around 50% in women under 35 years of age. By contrast, rates of surgery among older women have been increasing