Menorrhagia Update. Simon Edmonds Middlemore Hospital Ascot Central Women s Clinic Auckland

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Arron Powell
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1 Menorrhagia Update Simon Edmonds Middlemore Hospital Ascot Central Women s Clinic Auckland

2 What is it? Subjective Excessive blood loss at time of menstruation flooding heavy clots Objective > 80mls volume loss per menses Low Hb Low ferritin Does not matter, if symptomatic Cultural Racial Religious Personal

3 Victorian times Part of a woman s natural lot in life Hysteria (from Gk meaning womb) regularly diagnosed - menses a symptom of this

4 Herbs Historical Treatments

5 Historical Treatments

6 The uterus S

7 What does a pelvis look like?

8 Why is it an issue now? Commonest cause of iron deficiency anaemia in women of reproductive age Significantly affects QoL scores ltd to house socially embarassing inability to work expensive.even if normal Hb

9 Menorrhagia 1 in 20 women age years consults her G.P. each year Pre-menopausal women having hysterectomies in NZ 80% (3500) for menorrhagia 1990s approx 65% or less in 2000s Risk of hysterectomy under the age of 50 NZ 20% UK 17% USA 40% Denmark 10%

CMDHB Grading Between 100-150 GP referrals per

10 CMDHB Grading Between GP referrals per week 15% colposcopy Of the remaining: 22% are for Menorrhagia approx. 800 per year Virtual letters fertility/pcos/insufficient info/ Mx plans

11 Who should Manage it? At least 70% of case are due to DUB dysfunctional uterine bleeding just the hormones hormone imbalance NO true pathology that requires surgery.. So why not manage in primary care?

12 Secondary/Tertiary Care

13 Interface Providing the tools to assist primary care in: diagnosis referral for further tests recommended treatment pathways referral for specific surgical treatment

15 Tools and resources for Mx Appropriate training guidelines practical training in pipelle/mirena Appropriate access to tests ultrasound Appropriate renumeration/time

16 Diagnosis of exclusion Dysfunctional uterine bleeding, acute PID Fibroids outside cavity or submucous Polyps Endometrial hyperplasia.. Endometrial cancer.. Cervical cancer Clotting abnormalities etc

17 What can Primary Care do? Hx risk factors age >35 or 40? BMI >30 tamoxifen IMB Oligomenorrhea/PCOS Vaginal examination if <10 weeks, normal

18 What can Primary Care do (2)? Medical Management tranexamic/mefenamic acid provera/net D5-25 POP/COCP/Depo P/Jadelle

19 What can secondary care do? Realise that integrated care model keeps the patient in the community Support primary care to implement next level of tests/treatment Provide funding and expertise

20 What can secondary care do? What is the roadblock?... Ultrasound scanning..

21 TV U/S is the most important investigation in Gynaecology

22 1 st published work related to medicine: Transmission ultrasound investigation of the brain

23 1960s to 2000s Rapid technology advances grey scale still to real time development of Doppler Colour Doppler microchip processing power power Doppler 3D imaging

24 Why is ultrasound so important?

25 Ultrasound allows Investigation of symptoms Exclusion of pathology -GP Diagnosis of pathology - Hospital

26 ET Ovarian cysts Polyps Fibroids

27 The next investigation? Endometrial pipelle sampling

28 Endometrial Sampling

29 Endometrial Sampling

30 What else can secondary care do? Pilot study at CMDHB Facilitate pipelle endometrial sampling by GPs Provide a training package and credentialling document Have clear guidelines and flow charts for patient selection Create funding models for pipelle sampling ultrasound clinic visits

Pharmaceutical treatment as per guideline No structural or histological abnormality suspected Structural abnormality or risk factors: Hb < 80g/dL > 3/12 IMB > 3/12 failed treatment BMI > 30 Age > 35

31 Pharmaceutical treatment as per guideline No structural or histological abnormality suspected Structural abnormality or risk factors: Hb < 80g/dL > 3/12 IMB > 3/12 failed treatment BMI > 30 Age > 35 Transvaginal ultrasound + endometrial pipelle ET <12mm Normal or insufficient pipelle ET 12-15mm Must have adequate pipelle ET >15mm Pipelle and refer GOPD Continue medical Rx Consider mirena Normal pipelle Continue medical Rx Consider Mirena Abnormal pipelle Insufficient sample Continued Bleeding Any Abnormal Pipelle or Failed medical Rx > 6 months Refer GOPD

32 Can it be done? Trained 39 GPs through the outpatient hysteroscopy clinic GP champions Funded package x3 consults/pipelle + TV U/S + mirena Virtual clinic Governance Data collection

33 Pipelle and ultrasound vs Outpatient hysteroscopy

34 Mirena Coil. Treatments

35 Treatments Minimal Access Endometrial resection

36 Endometrial Ablation Global destruction of the endometrium. Novasure Balloon TCRE Microwave

38 All women should try this once Select appropriate group low BMI normal endometrial sample if fibroids < 10/40 >age 40 failed/unkeen on mirena 89% avoidance of future hysterectomy over 8 year follow up period Does hydrothermal ablation avoid hysterectomy? Long-term follow-up Julia Kopeika; Simon E. Edmonds; Gautam Mehra, Mohamed A. Hefni. Am J Obstet Gynecol 2011;204:207.

39 Hysterectomy.. Treatments

40 Medicine, mirena, endometrial ablation.. Hysterectomy is the final option.. Most of these should be done laparoscopically.

41 Why is BMI an issue? Women >90kg or BMI>35, ET>12mm - up to 40% have Endometrial Hyperplasia ET<12mm - less than 1% have Endometrial hyperplasia Obesity is the biggest risk factor

42 Case Histories (1) 34 year old woman, Para3 heavy periods 5 months, no IMB Hb 92 clinical examination normal 3 months of cyclical progesterone, tranexamic acid, iron No improvement, Hb now 102 TV U/S ET 10mm Mirena insertion settled by 6 months

43 Case Histories(2) 39 year old woman, nullip, BMI 39 irregular periods 5 months, Hb 112 clinical examination normal 3 months of cyclical progesterone, tranexamic acid, iron vs TV U/S ET 19mm. Pipelle sample: endometrial hyperplasia OPD Hysteroscopy Directed Bx simple Mirena coil

44 Case Histories(3) 27 year old woman, Para 1 heavy periods 5 years, BMI 61 Hb 89 clinical examination normal TV U/S ET 17mm Pipelle at least complex hyperplasia GA Hysteroscopy frond like lesion at fundus Histo: Endometrial CA. MRI stage 1b TAH + BSO pelvic nodes +ve Stage upgraded

45 Conclusions (1) Offer treatment to all women once risk factors excluded Consider upskilling in pipelle sampling mirena coil insertion Obesity is the biggest risk factor

46 Conclusions (2) DHBs have to provide appropriate and timely TV U/S access Remember endometrial ablation Refer for interventions hysteroscopy/endometrial ablation/hysterectomy

47 Team approach Conclusions (3)

48 Patient Education GP Information CMDHB/Womens Health/obstetrics + gynaecology

49 Thank you

Mr Doug Barclay Gynaecologist Ascot Central Women s Clinic Auckland. Mr Simon Edmonds Gynaecologist Middlemore Hospital Auckland

Mr Doug Barclay Gynaecologist Ascot Central Women s Clinic Auckland Mr Simon Edmonds Gynaecologist Middlemore Hospital Auckland 16:30-17:25 WS #69: Practical Mirena Insertion and Pipelle Endometrial Sampling