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 for 10-25% of all referral to gynaecology clinics. It is defined by NICE as excessive menstrual loss that interferes with the woman social, physical, emotional and material quality of life. It can occur with other symptoms like severe dysmenorrhea or PMT. The aim is to improve her quality of life. Take a full history of the severity of the bleeding, cyclicity, duration and other associated symptoms.
If regular heavy bleeds without structural or histological abnormalities, start medical treatment without physical examination. If history is suggestive of structural or histological abnormalities, like IMB, PCB, or pelvic pain, carry out physical examination and/or pelvic scan. It is not recommended to measure the menstrual loss by alkaline haematin or Pictorial blood loss chart. Laboratory tests; FBC, do not test for Ferritin. Do not test the hormonal profile or the thyroid function if no other symptoms or signs. Test for Von Willibrand Disease, if heavy menstrual bleeding since menarche or family history.
Consider pelvic scan if the uterus is palpable abdominally, pelvic mass is felt on vaginal examination and/ or failed pharmacological treatment. Ultrasound scan is the first line diagnostic tool. Saline infusion sonography should not be first line tool. Hysteroscopy if abnormal scan findings, thick endometrium, polyp, sub mucous fibroid and whenever endometrial biopsy is indicated. MRI is useful to assess fibroid size, location, number and vascularity to select and plan appropriate treatment. Endometrial biopsy to exclude endometrial cancer or atypical hyperplasia, is indicated if; >45 years old, persistent intermenstrual bleeding and / or failed medical treatment.
Patients counselling; The clinical findings should be explained and all treatment options discussed. The impact of treatment modality on fertility like uterine a. embolisation, myomectomy, endometrial ablation must be made clear. Adequate time and support in the decision making process should be allowed and a second opinion is offered if no agreement on treatment option. Pharmacological treatment; Mirena coil (LNG-IUS) the device release 20Microg. LNG daily. It lasts up to 5 years and recommended for the long term use (at least 12 months). IMB is common in the first 6 months. Patient satisfaction with Mirena at 12 months in 60-80% and amenorrhea rate is 15-35%. Expulsion rate of the coil is 10%. LNG-IUS compares favourably with oral progestogens, endometrial ablation and hysterectomy.
Tranexamic acid, is an antifibrinolytic, it reduces menstrual loss by 45 to 56%. It also reduces menstrual loss in women with HMB due to IUCD. It is more effective than NSAIDs 50% versus 25%. Side effects are dose related. 30% will experience gastrointestinal side effects with a dose of 3-6 gm.daily. Limiting the number of days to the first 3 days of the period will reduce them. Tranexamic acid did not increase the risk of serious side effects as thromboembolic disease in women who are not predisposed because of past history or family history of thrombophilia. Antiprostagalndins (NSAIDs) is popular in the treatment of menorrhagia and dysmenorrhoea. Mefenamic acid is the most often used and it reduces menstrual loss by 25% in 75% of patients. It is more effective than progestogens and has less side effects than Danazol. Treatment with Tranexamic acid and NSAIDs should be stopped after 3 months if not effective, but can continue as long as it is beneficial.
Oral progestogens; Norethisterone is effective in the treatment of ovulatory DUB if given at a higher dose of 15mg/day for 3 weeks out of 4 weeks. A lower dose in the luteal phase can help patients with non-ovulatory DUB, but not recommended by NICE. Combined oral contraceptive pill; reduces menstrual loss by 50%. In the absence of obesity, smoking and family history of thrombophelia, COCP can be continued after the age of 35 years. Gonadotrophine Releasing Hormone Analogues (LHRH analogues) by downregulating the pituitary and ovarian suppression lead to amenorrhoea. It can be used before surgery or whenever other treatments had failed. If used longer than 6 months, add-back HRT is recommended. Danazol should not be used routinely for HMB because of side effects. Etamsylate should not be used for treatment of HMB.
Endometrial Ablation (EA ); for women with HMB that impacts severely on her quality of life and she does not want to conceive. Women should be advised against pregnancy and must use effective contraceptive after EA. EA is offered if the uterus is of normal size ( <10 weeks pregnancy) with small fibroid <3 cm. At 2 years follow up, 59% of women on medical treatment had surgical treatment while only 17% required further surgery after EA. First generation EA technique ( endometrial resection) is appropriate for abnormal uterine cavity due to sub mucous fibroid, polyp or septum. Second generation EA, Tissue Impedence-controlled bipolar radio frequency ablation (Novasure )is the only and most commonly used, suitable in the absence of structural abnormalities, for outpatient use, does not require endometrial thinning, and quick ( treatment cycle is completed within 2 minutes)
Dilatation and Curettage, is not therapeutic. Uterine fibroids and HMB; women with large fibroids, dysmenorrhoea and pressure symptoms should be offered surgery or uterine artery embolisation (UAE). The impact of treatment option on fertility should be discussed. Before myomectomy or UAE, MRI scan should be arranged to asses the size, number, position and vascularity of fibroids. Pre-surgical treatment with LHRH analogues for 3-4 months whenever the uterus is large and distorted. Esmya ( Ulipristal, SPRM) it leads to anovulation, reduce menstrual loss and amenorrhoea. It is licensed for preoperative treatment as it reduces the fibroid size and vascularity. Now intermittent courses are allowed up to 4 courses. Myoma size was reduced by 50% after 2 courses and 70% after 4 courses. Myoma Size reduction was maintained after Esmya in comparison to LHRH analogues.
Esmya (Ulipristal Acetate) Esmya may carry a risk of serious liver injury, hence the restricted indication: * For intermittent treatment of severe symptoms of uterine fibroids in women of reproductive age and non legible for surgical treatment. * For one treatment course ( up to 3 months) of preoperative treatment of uterine fibroid. New Contraindication in women with history of liver disease. Requirements for liver function monitoring: LFT should be checked before starting treatment course, monthly during treatment and 2-4 weeks after stopping treatment. Do not start treatment if levels of ALT or AST are > 2times the upper normal limit. Stop treatment if AST or ALT levels are > 3 times the upper normal limit. Advice patients to look out for signs and symptoms of liver injury, when treatment must stop.
Hysterectomy; only considered when other treatment options had failed, contraindicated or declined. The woman wishes amenorrhoea and no longer wishes to retain fertility. Serious complications; like haemorrhage, infection, other organs damage and loss of ovarian function even if the ovaries are conserved. Hysterectomy route will depend on; uterine size, previous surgery, uterine mobility and descend, shape of the vagina and other gynaecological disease. LAVH will facilitate removal of the ovaries during vaginal hysterectomy. Total versus subtotal hysterectomy should be discussed with the patient. Removal of the ovaries; should not remove healthy ovaries, and only removed with woman consent. The impact on woman health and need for HRT should be explained. Those with family history of ovarian and breast cancer, should have genetic testing before oophorectomy. Young woman <45 years, with PMT, should have 3 months therapeutic trial of LHRH analogues to assess the need for oophorectomy.
Uterine artery embolisation; less invasive than myomectomy or hysterectomy with faster recovery and uterine preservation patient should be aware that symptoms relief may not be achieved, further procedures may be required and the effect on fertility is uncertain. 83% reported symptoms improvement at 24 months, but improvement was more significant after surgery than UAE. Fibroid size was reduced by 40% and re-intervention rate was 15% at 3 years and 28% at 5 years. Pregnancy was achieved by 50%of women after UAE, while 78% after myomectomy. Spontaneous miscarriage occurred in 64% after UAE, vs 23% after myomectomy. Infection occurred in 2-3% after UAE, and can lead to septicaemia necessitating emergency hysterectomy or myomectomy.
HMB, Ambulatory Gynae. Outpatient Hysteroscopy Clinic, for one stop management of menstrual disorders; HMB >45 years of age, IMB and persistent bleeding, abnormal scan findings, missing IUCDs and PMB. Patients will have pelvic scan, full history taken, pelvic examination and hysteroscopic assessment. Findings are discussed with the patients and endometrial biopsy taken. If all findings are normal, with the patient consent; LNG-IUS can be fitted. If abnormal endometrial cavity, small polyps can be removed in the clinic with bipolar Versapoint twizzle. Larger polyps or submucous fibroids can be removed by Myosure device as outpatient procedure or under GA as Transcervical Resection of Endometrium and fibroid. If the patient is requesting EA, has normal endometrial biopsy and had completed her family, Novasure EA is carried out as an outpatient procedure under LA.
HMB & Ambulatory Gynaecology Thank You