Vani Lingam Consultant Obstetrician and Gynaecologist Queens Hospital Burton NHS Trust 13 th June

Vani Lingam Consultant Obstetrician and Gynaecologist Queens Hospital Burton NHS Trust 13 th June

Definition of normal menstruation Cycle Length Cycle predictability Duration Volume of blood flow

Cycle Length Number of days from day 1 of one menstrual period to day 1 of the next menstrual period Normal cycle length from 22 to 35 days Later in the reproductive year, cycle length tends to be come shorter

Duration of menstrual Flow NICE guidelines Normal duration is between 3-8 days

4 Key menstrual dimension Regularity irregular, normal or absent Frequency- frequent, normal or infrequent Duration- prolonged, normal or shortened Volume- heavy, normal or light

Regularity Regular - +/- 2 to 20 days Abnormality 1- irregular variation > 20 days Abnormality 2 - absent

Frequency Normal 24-38 days Abnormality 1- Frequent <24 days Abnormality 2 Infrequent >38 days

Duration Normal 4.5-8 days Abnormality 1 Prolonged >8 days Abnormality 2 Shortened <4.5 days

Volume Normal Abnormality 1 Heavy Abnormality 2 - Light

Intermenstrual Bleeding Bleeding that occurs between cyclically normal menstrual bleeding May be related to contact, or spontaneous, maybe cyclical or occurs at random times between periods

Breakthrough Bleeding Unscheduled uterine bleeding that occurs in association with the use of gonadal steroids or other agents designed to suppress endocrine regulation of the endometrial function

Acute and Chronic Abnormal Uterine Bleeding Chronic AUB- bleeding that is abnormal in volume, regularity and/or timing which has been present for at least 3 months Acute AUB is an episode of sufficient volume to require urgent or emergency intervention

Classification of AUB Uterine Polyp Adenomyosis Fibroids Malignancy /hyperplasia Coagulopathy Ovulatory dysfunction Endometrial Iatrogenic

Chronic AUB If cyclical predictability present HMB is due to conditions such as adenomyosis, fibroids, coagulopathy and endometrial pathology Intermenstrual bleeding is normally due to polyp

Chronic AUB Totally unpredictable bleeding outside the context of regular and predictable periods are associated with ovulatory disturbances It might be an indication of endometrial hyperplasia or malignancy

Investigation of AUB History- accurate history including normal menstrual pattern, timing, volume and associated symptoms? Affecting quality of life

History Cyclical predictable What is complaint? Intermenstrual bleeding -?polyp Heavy MB-?adenomyosis, fibriods, coagulopathy, endometrial

History Unpredictable bleeding HMB & or unpredictable AUB Cause? AUB-O or AUB- M

Physical Examination Look for sudden weight loss, obesity, bruising, endocrine problems, anaemia Inspection of perineum to exclude local causes Speculum examination -?cervical polpy, ectropion, cervical tumour, cervicitis Bimanual examination- pelvic mass, fibroid, adenomyosis

Investigation Measurement of Hb/ serum ferritin Coagulation studies Thyroid Function Luteal phase progesterone

Evaluation of Uterus Histological evaluation endometrial biopsy Ultrasound Hysteroscopy

Ultrasound Typically endometrial thickness is measured and reported as a sum of two adjacent layers of endometrium- called the endometrial echo complex Typically the EEC is 4mm in the menstrual phase up to 12mm in the the luteal phase

Ultrasound Thickness can vary in the presence of ovulatory disorders? What is the upper threshold One study suggest that as long as the endometrial thickness is 12mm or less, there is low incidence of hyperplasia or neoplasia

Management of HMB Mirena IUS Tranexamic acid-1g qds COC- Qlaira Progesterone noretheristone, depo-provera Danazol- 400-600mg/day for patient with ITP

Mirena IUS Reduction of 81.6% in blood loss at 3 months and 95.8% at 12 months No difference between Mirena IUS and endometrial ablation Benefit in dysmenorrhoea related to adenomyosis or endometriosis PMS/ HRT protection

Tranexamic Acid When used 1 g qds for 4 days is associated with a 40-60% reduction in bleeding volume It does not increase risk of thromboembolic disease even when used in women at high risk Safe to use

Cyclooxygenese inhibiotrs In women with menorrhagia, mean reduction in blood flow was 20% ( 5 of the 7 RCT) Dose- start on first day of period for 5 days or until period stops Mefenamic acid- 500mg tds Ibuprofen 600-1200md/day Benefit for accompanying dysmenorrhoea

Progesterone Cyclical fashion norethisterone 5mg tds from day 5 to day 26 reduced blood loss by 87% Continuous administration no clinical trials /evidence NET- 5-15mg/day MPA- 30-40mg/day Depo- provera

Combined OCP A single study showed menstrual blood flow reduction by 50% Another study showed 80% improvement compared with 26% receiving placebo Qlaira- NICE approved for HMB showing blood reduction up to 87%

Management of AUB in primary care Define possible cause Investigation according to differential diagnosis Ultrasound scan, fbc, etc

Management of AUB in primary care How is AUB affecting QOL? What are patients expectations? Discuss medical options- explain that Mirena IUS as effective as endometrial ablation. Hysterectomy is cure but potential morbidity/mortality

Management of AUB If medical options accepted, plan to improvement of symptoms within 3-6 months If no success, referral into secondary care

Surgical Treatment Endometrial ablation Hysterectomy

Acute AUB Modestly heavy to excessive bleeding associated with hypovolumeic shock If patient unstable- refer into hospital If stable- consider management in primary care

Investigation Exclude pregnancy History and physical examination exclude trauma, molar pregnancy, degenerating fibroid polyp etc Medical treatment as out patients

Management Option 1 Oral progestins- MPA 60-120mgs daily until bleeding stops for at least 2 days Then 20-40mg/day for 3-6 weeks 25% patients stop bleeding within 24 hours Remainder ceased bleeding by the 4 th day

Management Option 2 Another regimen is 60mgs of MPA in three divided doses for the first week Then continue with 20mgs/day for 3 weeks

Management -Option 3 Norethisterone 5-15mg daily until bleeding stops for at least 2 days Followed by 10mg daily for 3 weeks.

Management- Option 4 Combined oral contraceptive pill Monophasic pill oestrogen 35ug such as Norinyl Three to four times a day until bleeding stops for at least 2 day Then daily for 3-6 weeks eliminating placebo pills

Management Once bleeding has stopped, patient needs investigated Ultrasound scan and biopsy Management according to findings

Pelvic Pain Chronic pelvic pain is defined as pain that occurs below the umbilicus (belly button) that lasts for at least six months. It may or may not be associated with menstrual periods. Chronic pelvic pain is not a disease, rather, it is a symptom that can be caused by several different conditions.

Endometriosis Endometriosis - a condition in which endometrial tissue is also present outside of the uterus. Some women with endometriosis have no symptoms, while others experience marked discomfort and pain and may have problems with fertilty

Pelvic Inflammatory Disease Pelvic inflammatory disease is an infection caused by a sexually transmitted organism. Occasionally, it is caused by a previous ruptured appendix or scarring resulting from previous pelvic surgery. Pelvic inflammatory disease can cause pain, abnormal uterine bleeding, and symptoms of infections

Irritable Bowel syndrome is a gastrointestinal condition characterized by chronic abdominal pain and altered bowel habits (such as loose stools, more frequent bowel movements with onset of pain, and pain relieved by defecation) in the absence of any specific cause

Diverticulitis A diverticulum is a sac-like protrusion that sometimes forms in the muscular wall of the colon (or intestine). Diverticulitis occurs when diverticula become inflamed. This usually causes abdominal pain; nausea and vomiting, constipation, diarrhea, and urinary symptoms can also occur

Painful Bladder Syndrome the term given to pain in the tissues in the bladder and surrounding nerves and muscles that is not caused by infection. Symptoms include the need to urinate frequently (frequency) and a feeling of urgently needing to urinate (urgency). Some women with painful bladder syndrome have lower abdominal or pelvic pain in addition to urinary tract symptoms.

Pelvic Floor Pain The muscles of the pelvic floor can sometimes become shortened, tight and tender; this is called pelvic floor dysfunction. The pelvic floor includes muscles that attach to the pelvic bones and sacrum (lower part of the spine). Normally, these muscles function to support the hips and pelvic organs. It is not clear why this problem develops.

Pelvic Floor Pain Symptoms may include pelvic pain, pain with urination, constipation, pain with intercourse, or frequent/urgent urination. Pelvic floor dysfunction can be diagnosed by a clinician feeling the muscles in the vagina and/or rectum; muscles that feel tight, tender, or band-like indicate that pelvic floor dysfunction could be contributing to pelvic pain.

Abdominal myofascial pain Pain can originate from the muscles of the abdominal wall due to myofascial pain. This problem usually has small localised areas of abdominal tenderness of the abdominal muscles that are called trigger points. AMP is diagnosed by the clinician examining the abdominal muscles for trigger points- often tightening of these muscles while they examined causes increased pain and assist in diagnosis

Fibromylgia chronic pain disorders that affect connective tissue structures, including muscles, ligaments and tendons. It is characterized by widespread muscle pain (or "myalgia") and tenderness in certain areas of the body. Women with fibromyalgia may also experience fatigue, sleep disturbances, headaches, and mood disturbances such as depression and anxiety.

Investigation A thorough history and a physical examination of the abdomen and pelvis are essential components of the work-up for women with pelvic pain. In particular, the examination should include the lower back, abdomen, hips, and pelvis (internal examination).

Investigation Laboratory tests, including a white blood cell count, urine analysis, tests for sexually transmitted infections, and a pregnancy test may be recommended, depending upon the results of the physical examination. Laparoscopy and cystoscopy

Role of ultrasound scan Pelvic scan is accurate in detecting pelvic masses, including ovarian cysts (sometimes caused by ovarian endometriosis) and uterine fibroids. However, ultrasound is not helpful in the diagnosis of irritable bowel syndrome, diverticulitis, or painful bladder syndrome

Management of Chronic PP 1 st option is to prescribe sequential drug treatments for disorders that re the most likely cause of patient s pain eg endometriosis, infection 2 nd option - A different approach is to use intensive diagnostic testing in an attempt to identify specific cause of pain before starting treatment. This might involve costly laboratory, imaging tests and exploratory surgery 3 rd option is treatment directed at pain rather than at a specific diagnosis-nsaid, antidepressants, anticonvulsants

Physical Therapy Pelvic floor physical therapy can help in patients with myofascial pain and pelvic floor pain. This type of physical therapy aims to release the tightness in these muscles in the abdomen, vagina, hips thigh and lower back Physical therapy needs specialist skills- trained physiotherapist

Pain management clinic If conventional treatment has been unsuccessful, consider referral to pain clinic Uses multiple treatment modalities Acupuncture Biofeedback and relaxation therapy Nerve stimulation Injection of tender sites with local anesthetise Prescribe opiates

Symptoms of endometriosis severe dysmenorrhoea deep dyspareunia chronic pelvic pain ovulation pain

Symptoms of endometriosis cyclical or perimenstrual symptoms, such as bowel or bladder, with or without abnormal bleeding or pain infertility chronic fatigue dyschezia (pain on defaecation).

Examination Deeply infiltrating nodules are most reliably detected when clinical examination is performed during menstruation Adenomyosis- tender smooth uterus which is mobile

Diagnosis If a woman wants pain symptoms suggestive of endometriosis to be treated without a definitive diagnosis, a therapeutic trial of a hormonal drug to reduce menstrual flow is appropriate. Gold standard - laparoscopy

Endometriosis Mirena IUS OCP Depo-Provera Danazol GnRh Angonist- prostap/zoladex Treatment can be undertaken without diagnosis

Medical Treatment There is inconclusive evidence to show whether NSAIDs (specifically naproxen) are effective in managing pain caused by endometriosis. Suppression of ovarian function for 6 months reduces endometriosis-associated pain. Symptom recurrence is common following medical treatment of endometriosis.

Mirena IUS A systematic review identified two randomised controlled trials and three prospective observational studies, all involving small numbers and a heterogeneous group of patient. Nevertheless, the evidence suggests that the LNG-IUS reduces endometriosis-associated pain with symptom control maintained over 3 years

Medical Treatment Duration of therapy should be determined by the choice of drug, response to treatment and adverse effect profile. If after 3-6 months, no response, referral into hospital for laparoscopy

Surgical Management Ideal practice is to diagnose and remove endometriosis surgically Ablation of endometriotic lesions reduces endometriosis-associated pain Endometriosis associated pain can be reduced by removing the entire lesions in severe and deeply infiltrating disease.

Management of Pelvic Pain Exclude infections-if infection screen positive, treat and reassess Ultrasound scan to exclude ovarian cyst, fibroids, endometrioma etc If symptoms suggestive of endometriosis, start treatment without the need for diagnosis If after 3-6 months, no improvement to refer for laparoscopy

Painful Bladder syndrome Negative urine culture Referral to continence team for bladder retraining Urinary frequency and urgency, treat with anticholinergic Bladder diary to include food diary- patient to avoid acidic foods such as tomatoes, caffeine, pineapples etc

Medical Treatment of PBS Hydroxyzine 10mg nocte increasing according to symptoms Cimetidine 400mgs bd Amitryptyline/ nortriptyline Gabapentin Pregabalin

Painful Bladder Syndrome If symptoms not improved, referral for cystoscopy with cystodistention Bladder instillations with cystistat, uracyst etc Elmiron (Pentosan Polysulphate) Botox, bladder diversion and cystectomy

Indication for HRT acute menopausal symptoms flushes, night sweats mood change poor sleep, tiredness memory disturbance quality of life urogenital symptoms vaginal dryness dyspareunia reduced libido premature menopause

Urogenital Atrophy Affects vagina and bladder Underreported and undertreated Vaginal dryness, dyspareunia, reduced libido 2/3 women by the age of 75

Under reporting 20-25% with symptoms seek help One survey- 78% feeling active sex life important 59% hide symptoms from partner

Under treating 25% with genito-urinary symptoms who seek help receive treatment

Premature Menopause Age < 40 years If untreated there is increased risk of CHD Osteoporosis Dementia Usual Advice to replace hormones to age 50 years. These years not counted in risk assessment

Is HRT Safe? Does it cause? Heart attacks/stroke Breast cancer Ovarian/endometrial cancer Thromboembolism What do we tell patients???

Communicating risk Relative Risk (RR) takes no account of incidence Absolute risk estimates the number of extra cases in a population

HRT & CHD risk WHI 2002 30% increase (RR1.29) 7extra cases per 10,000 women years Years since menopause <10yrs 10-19 yrs >20 yrs -6 +4 +17 Age group 50-59 60-69 70-79 -2-1 +19

What to tell patients about heart attacks HRT use within 10 years of menopause has not been shown to increase risk for heart attacks

HRT & Stroke risk WHI 2002 40% increase (RR1.41) 7extra cases per 10,000 women years oestrogen + progestogen oestrogen alone 50-59 yrs 4 0 60-69 yrs 9 19 70-79 yrs 13 14

What to tell patient about strokes Both E and E+P increase risk of stroke Risk increases with age Smoking, obesity, hypertension increase risk Approx 1 extra stroke in 1000 users in 5 years

HRT and Breast cancer risk oestrogen + progestogen oestrogen alone 50-59 yrs + 3-4 60-69 yrs + 4-5 70-79 yrs + 7-1

What to tell patients about breast cancer E+P increases risk Risk is duration dependent Overall risk is in 50-59 years group is 3 extra cases in 1000 women in 5 year use No apparent risk < 5 years No apparent risk E alone < 7 years

HRT and endometrial cancer May increase 2 folds in sequential therapy > 5 years Reduced risk in CCHRT (not tibolone) Endometrial hyperplasia with vaginal premarin

HRT and ovarian cancer WHI- no risk MWS- 1 extra ovarian cancer in 2,500 user over 5 years with 1 extra death in 3,300 users over 5 years

HRT and VTE Risk of VTE increases with age, obesity etc Background risk 50-59 years is 1 per 1000 per year and 2 in 60-69 HRT increases risk 2-3 folds Highest risk in first year of use Transdermal avoids first pass? Safer

MWS in Jan 2012 Cancer detected within few months of study would have already been present and these were not excluded in analysis Study participants were from breast screening programme. This invitation could have led to higher number of cancers being detected (detection bias)

MWS in Jan 2012 Even a small detection bias, accounting for 1-1.9 extra cases a year in HRT users would have invalidated the findings The average time from recruitment to detection of breast cancer of 1.2 to 1.7 years and the likelihood of fatal cancer being 22% higher amongst HRT users within this short time frame was biologically implausible

MWS in Jan 2012 Recent critique of MWS with its flaws limited the ability to establish a casual association (if one exists) between HRT and breast cancer A recent WHI trial also has suggested failure to establish causality and the fall of breast cancer rates in UK predated the publication of MWS

Missing points Menopausal symptoms are debilitating. Majority use HRT for valid reasons having weighed up pros and cons HRT discussed as if it were one entity with identical benefits and risk outcomes. Studies were done 20 years ago and now preparations are lower dose often transdermal and identical to endogenous hormones

Future? Pilot studies using lower dose endogenous type hormones in younger women are due to report in the near future and are expected to show favourable outcomes

Take Home Message Use HRT for a few years in symptomatic women in their early 50s Reassess needs every year and aim to stop treatment where possible after 5 year use Patients with premature ovarian failure should continue until, aged 50 years

Case 1 A 36 year old Para 2, comes to you with a history of heavy periods. Her partner has had a vasectomy. Discuss her management

Case 2 A 40 year old patients comes to your surgery stating that over the past 4 months, she has notice her periods are heavier and she has bleeds half way through her cycle which last for one day.

Case 3 A 43 year old patient with a BMI of 45, very distressed as she has been bleeding every two weeks for the past 3 months and is now feeling very tired. She wants you to refer her to the hospital for a hysterectomy!!

Case 4 A 47 year old presents with persistent post coital bleeding for the past 4 months. Her periods are regular every 26 days, with normal blood loss.

Case 6 A 45 year patient comes to see you with a history of heavy periods but more recently has become more painful. She states that on day 2 she has labour type pains and the last period the pain was so severe that she past out and was sent home from work

Case 5 A 42 year old patient comes to see you with bleeding mid-cycle over the past 4 months. You saw her and fitted her with the Mirena IUS 18 months ago.

Case 7 A 18 year old patient comes to see you with a history of pelvic pain as she now has got to the stage that she cannot have sexual intercourse with her boyfriend and this is causing her to have relationship problems

Case 8 A 41 year old patient comes to you stating that she is experiencing pain around the time of ovulation, with pain radiating down her legs, feeling very tired and now having painful intercourse as well.

Case 9 A 57 year old patient who comes to see you with a history of painful intercourse. She has been a widow for 8 years and has now started a new relationship

Case 10 A 64 year old pain comes to see you with a history of lower abdominal pain.