Excessive menstrual blood loss

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Liliana Terry
5 years ago
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1 Ian Chilcott

2 Excessive menstrual blood loss >80mls - That interferes with physical, emotional, social and material quality of life 1 in 20 women aged 30 to 49 years consult their GP each year with menorrhagia Single leading cause of referral to gynaecologist

3 Causes Idiopathic. DUB Fibroids Endometrial polyps Endometrial hyperplasia Adenomyosis Thyroid disease Haemostatic disorders

4 FBC (TFT Clotting disorders Hormonal profile) Ultrasound Uterus palpable abdominably Pelvic mass of uncertain origin Failed pharmaceutical treatment

5 Endometrial biopsy (persistent IMB >45 with treatment failure to exclude hyperplasia/malignancy) Endometrial sampling Hysteroscopy

6 27% pts with abnormal uterine bleeding submucosal fibroids

8 Appropriate if: No structural or histological abnormality abnormality (fibroids <3cm not distorting cavity)

10 Mirena (levonorgestrel-releasing intrauterine system) 20mcg LNG/24 hrs over 5 years Reduces menstrual loss by up to 96% 20% amenorrheic at 1 year Use also contraception - progestogen component of HRT

11 Dilatation and curettage Myomectomy Hysterectomy Endometrial ablation TCRE TCRF Myomectomy Hysterectomy - Laparoscopic

12 Fibroids Symptoms correlated with location as well as size Grade 0 Grade 1 Grade 2

16 1 st generation Endometrial resection/ablation LEA Rollerball EA TCRE

17 Resection TCRE Day case Tissue obtained Gold standard Endometrial preparation Complications Training issues

18 TCRE Gold standard technique 77% success at 5 years Litta et al - Eur J Obstet Gyn Reprod Biol 2006 Various other studies Amenorrhoea rate 30-40% Success 70-90%

19 TCRE Complications Fluid absorption >2l 1% Uterine perforation 15/1000 Bowel injury 0.7/1000 Emergency hysterectomy 11/1000 Mistletoe study, Overton BJOG 1997

20 2 nd Generation Endometrial Ablation Non hysteroscopic Easier Quicker Safer 2nd Generation Endometrial Ablation

21 Balloon ablation Thermachoice Caverterm Thermablate Microwave endometrial ablation MEA Novasure Hydrothermal ablation Endometrial cryo ablation 2nd Generation Endometrial Ablation

22 Balloon ablation Thermachoice 1 st of the second generation devices 2nd Generation Endometrial Ablation

23 Balloon ablation Thermachoice 2nd Generation Endometrial Ablation

24 Balloon ablation Thermachoice 2nd Generation Endometrial Ablation

25 Thermachoice Vs TCRE Gervaise Hum Reprod 1999;14 RCT N=147 2 years TCRE Thermachoice Low complication rates Satisfaction 76% 83% Amenorrhoea 38.8% 36.4% Hysterectomy 10% 15% 2nd Generation Endometrial Ablation

26 Thermachoice Vs Rollerball Meyer Obstet Gynecol 1998;92 RCT N=239 Rollerball Thermachoice 2 years Satisfaction 85.6% 86.7% Amenorrhoea 15.2% 27.2% 5 years Overall success 69% 68% 2nd Generation Endometrial Ablation

27 Thermachoice Vs Rollerball Meyer Obstet Gynecol 1998;92 RCT N=239 Rollerball Thermachoice 2 years Satisfaction 85.6% 86.7% Amenorrhoea 15.2% 27.2% 5 years Overall success 69% 68% 2nd Generation Endometrial Ablation

28 Balloon ablation Thermachoice Complication rates Gurcheff and Sharp Medline/FDA database Estimated denominator Overall complication rate 0.59/1000 2nd Generation Endometrial Ablation

29 2nd Generation Endometrial Ablation

30 Mean treatment time 3.5 minutes Therapeutic zone 70-80C

31 MEA VS TCRE Cooper et allancet 1999;354 N= months MEA TCRE Amenorrhoea 40% 40% Satisfaction 78% 76% 2nd Generation Endometrial Ablation

32 A randomised comparison of MEA Vs TCRE: F/U at min 5yrs BJOG 2005 Cooper et al N=239 MEA TCRE Satisfaction 86% 74% Acceptability 97% 91% Amenorrhoea 65% 69% Hysterectomy rate 16% 25%

33 2nd Generation Endometrial Ablation

34 3-D Bipolar electrode Myometrial Penetration: Cornua mm Mid-Body mm Depth of ablation controlled by impedance of the tissue: 2nd Generation Endometrial Ablation

35 1. Device insertion and deployment 3. Ablation cycle with bipolar RF energy- 90 seconds. 2. Cavity integrity assessment 8 secs 2nd Generation Endometrial Ablation

36 Consistent Depths of Tissue Destruction Across Varied Uterine Sizes (post-ablation specimen)

37 90 secs

38 Thermachoice Vs Novasure Bongers BJOG 2004;111 RCT N=126 1 year Novasure Thermachoice Satisfaction 90% 79% Amenorrhoea 43% 8% Low complication rates 2nd Generation Endometrial Ablation

39 No tissue sample Expensive as disposable equipment Treatment outcomes broadly similar to HEA and between 2nd generation techniques Good safety profile User friendly Shorter operating times Out patient treatments possible Effective Likely to increase in popularity 2nd Generation Endometrial Ablation

40 The aim of UAE for fibroids is to offer a less invasive alternative to hysterectomy or myomectomy with preservation of the uterus Conscious sedation local anaesthesia catheter is inserted into the femoral artery Fluoroscopic guidance,into the uterine artery. Small embolisation particles are injected through the catheter into the arteries supplying the fibroids, with the aim of causing thrombosis and consequent fibroid infarction. 40% reduction in uterine size Patient selection important

41 Abdominal Laparoscopic Vaginal

42 The role of laparoscopy Vaginal hysterectomy - advantages over abdominal procedure Laparoscopy - allows conversion of an abdominal procedure to a vaginal one

44 Classification 1. Diagnostic laparoscopy, vaginal hysterectomy 2. LAVH Adnexae, adhesions, but uterine arteries taken vaginally 3. LH Uterine arteries taken laparoscopically 4. TLH

Menstrual Disorders & Ambulatory Gynaecology

Menstrual Disorders & Ambulatory Gynaecology Mr. Nagui Lewis Aziz M B, CH B, FRCOG Consultant Gynaecologist The Royal Oldham Hospital 01/09/2018 Heavy menstrual bleeding (HMB ) is a common problem responsible