Dr Devashana Gupta Repromed Auckland 17:30-18:00 Fibroids, Endometriosis and DUB
Fibroids, Endometriosis and AUB Dr Devashana Gupta 9 th June 2018
Abnormal uterine bleeding PALM-COEIN 3
What is abnormal bleeding Bleeding outside of the normal menstrual cycle length (21-35 days) and outside of the normal parameters i.e. >80mls/cycle! HMB- no longer menorrhagia 1 in 5 women suffer from heavy periods 50% of women with HMB have pelvic pain 77% of women with heavy periods have depression and moodiness 63% of women report missing social activities due to their heavy periods 84% of women with heavy periods report having less energy or no energy at all 4
5 How heavy is heavy?
Endometrial/endocervical polyps - AUB-P Epithelial proliferations, consisting of vascular, glandular, fibromuscular and connective tissue cells Often asymptomatic but a/w HMB Polyps may interfere with fertility but controversial CR 2015: OR 2.45 for clinical pregnancy with removal of endometrial polyp prior to IUI treatment Therefore, historically recommend removal of polyps >2-3cm if undergoing IUI/IVF 6
Adenomyosis- AUB-A Endometrial tissue within muscle of uterus, 5-60% prevalence Used to be called endometriosis interna, no longer under one disease entity. Unknown etiology. Possible abnormal migration of endometrium into myometrial layer Causes uterine enlargement, heavy menstruation and dysmenorrhea, dyspareunia. 33% asymptomatic. Diagnosis: histology at hysterectomy. >10*6 endometrial glands in muscle. USS- venetian blind effect, globular and enlarged uterus MRI can be useful pre-operatively Rx: NSAIDs, hormonal treatment, curative = hysterectomy. 7
Fibroids/Leiomyomas AUB-L Benign fibromuscular tumors of the myometrium Common and maybe asymptomatic in a large portion of the population Symptoms: HMB, pressure effect, bladder/bowel symptoms Diagnosis: USS. MRI if further assessment required for diagnosis of malignancy. Leiomyosarcoma 0.5-1%. <30% 5 yr survival Treatment- hormonal, UAE, MRgFUS, surgery- uterine sparing plus non sparing 8
9 Fibroid classification FIGO
Uterine fibroids and fertility management ACCEPT guidelines 2011 Effect on fertility (Level 3 evidence) SS don t appear to have an effect IM may be associated with reduced fertility and increased miscarriages SM associated with reduced fertility and increased miscarriages Management of fibroids in infertile women Hysteroscopic resection likely to improve fertility outcomes (level2) IM insufficient evidence to determine benefit (Level 2) Fibroid size, number and location may impact on the usefulness of myomectomy Indications for myomectomy Infertile woman with SM fibroid (level 2) Infertile woman with symptomatic fibroids (level 4) Previous multiple failed ART cycles with IM fibroids (level 4) 10
Myosure tissue removal system 11
Malignancy/hyperplasia- AUB-M Endometrial hyperplasia Previous WHO94 classification: 4 groups- atypical hyperplasia (simple and complex) and non-atypical hyperplasia (simple and complex). Risk of malignancy 8-29% Newer WHO2014 classification: 2 groups- Benign hyperplasia (<5% risk of progression to malignancy over 20 yrs) and atypical hyperplasia/endometrial intraepithelial neoplasia (EIN) Endometrial adenocarcinoma Risk factors: unopposed estrogen, increased BMI, tamoxifen, nulliparity Cervical cancer 12
COEIN AUB-C: Coagulopathy- consider if HMB since menarche especially with family history. 13%in studies, largely VWD. AUB-O: Ovulatory dysfunction- anovulatory cycles tend to be irregular. AUB-E: endometrial issue e.g. infection, inflammation AUB-I: iatrogenic. E.g. hormonal medications, Mirena, warfarin AUB-N: not yet classified e.g. AVM 13
Medical management of AUB Any management needs to focus on improving QOL rather than just reducing the menstrual blood loss Ascertain preference and comorbidities, exercise and BMI Do nothing approach- doesn t really work! Treat the cause e.g. polyp Non-hormonal- Cyclokapron, NSAIDs* (20-46% reduction) Hormonal- cyclical progesterone, OCP*, Depo Provera, Mirena Mirena IUS- 3-6/12 to settle in. 97% reduction in HMB. Suitable for SM fibroids <3cm, adenomyosis and endometriosis. Pharmac subsidized if anemic. ECLIPSE trial. Less used- GnRHa, Danazol Ulipristal for fibroids- SPRM. Recently taken off the market- 4 liver failure cases 14
Surgical management of AUB Surgical removal of cause- fibroids, polyps Endometrial ablation Hysterectomy with conservation of ovaries, consider removal of fallopian tubes Uterine preservation surgery- UAE, MRgFUS *CR 2016- Mirena IUS, endometrial surgery and hysterectomy have highest reduction in HMB rates CR 2013- Endometrial surgery compared to hysterectomy. Short term ablation is more cost effective but this narrows with the reoperation rates are taken into account. Hysterectomy tends to be a longer operation, higher complication rate and longer recovery. 15
RF device for management of HMB Simple procedure that can be performed as a day stay and even outpatient. Newer devices have a 6mm diameter Safety checks in place that ensure cavity seal However, complications can still arise and include bowel injury Pre and post-op NSAIDs helpful Cramping and brownish discharge Long term contraception required as high risk pregnancy Novosure 16
Endometriosis Common, benign and chronic disease. No racial predisposition 6-10% reproductive age women Commonest cause of chronic pelvic pain- 35-50% Cause of infertility in 10-15% of couples, maybe more upto 35-80% in women undergoing laparoscopy for pelvic pain Adolescence and infertile women undergoing laparoscopy for dysmenorrhoea/infertility- 50% Financial burden $350million/year (Aus.)- diminished QOL, missed productivity, medical and surgical Rx and chronic nature 17
Endometriosis epidemiology & pathogenesis Protective: Increasing parity OCP: conflicting evidence: risk decreased in current users Smoking- anti-estrogenic effect Other risk factors: immune diseases such as RA, SLE Lifestyle and dietary factors- controversial Environmental exposures- E2 well established, dioxin and heavy metals such as cadmium also been implicated 18
Pathogenesis Proposed mechanisms Retrograde menstruation/implantation theory* Coelomic metaplasia theory Lymphatic or vascular spread theory/embolic Direct transplantation theory Altered immunity theory Mullerian rest theory Pluripotent stem cell theory 19
Symptoms and signs Asymptomatic 4 D s: dysmenorrhoea (90%), dyspareunia (comm deep- 75%), dyschezia and dysuria Cyclical pelvic pain Chronic pelvic pain (70%) Infertility (55%) Deceased QOL scores Other GI symptoms- PR bleeding, cyclical bloating, alternating bowels Other urological symptomshaematuria, urinary frequency and urgency 20
What causes pain & infertility? What causes pain: Micro-haemorrhages in implants with resultant inflammation Anatomy is distorted Nerve involvement: lesions innervated, predilection for nerve fibres Nociceptive mediators: inflammatory cells and mediators Chronic pain syndrome: central sensitisation thru denervation and reinnervation (Stratton and Berkley, 2011) Anatomical distortion in stages 3 and 4- impaired tubes/ovarian relationship, endometrioma Oocytes- reduced reserve, cytokines elevated Fertilisation- abnormal peritoneal macrophages Subclinical pelvic inflammation- altered peritoneal fluid Embryo quality- poor due to egg quality, toxic intraperitoneal, intratubal and endometrial environment Implantation receptivity- endometrial autoabs, abnormal cell adhesion molecules, adenomyosis 21
Tertiary level care for Severe Endometriosis Clearly defining and explaining the extent of the disease Providing appropriate counselling and psychological support Providing a nurse specialist who will interface between patient and specialist team Individualising care based on the patient s specific symptom complex and preferences Consideration of the patient s fertility needs Providing high quality treatment and care to relieve symptoms of endometriosis Assessing quality of life before, and at intervals after, treatment 22
Tertiary Service Providing complex laparoscopic surgical excision of all endometriosis Retaining pelvic structures unless there is an objective reason to remove them Maintaining a detailed surgical database to include detail of surgery and any complications Recording relevant clinical domains and quality of life Working with pain management specialists Keeping the use of open surgery to the minimum 23
Diagnosis Average time to diagnosis of 8 years! Believe that cyclical pain is normal Differing pain thresholds making seeking medical help difficult Other common causes of pain: PID and IBS sharing symptoms Lack of non- invasive diagnostic methods Differing macroscopic forms: dependent on surgeon s experience, location and type of lesion History and examination contributes majorly Tertiary endometriosis USS MRI Laparoscopy is however the only diagnostic test that is sufficiently accurate 94% sensitivity 74% specificity Non-invasive diagnostic tests: blood, endometrial, urine and combined 24
Ultrasound pelvis Endometrioma detection sensitivity 64-90% and specificity 90-100% Doesn t diagnose peritoneal endometriosis Useful for assessment of ovaries for endometriomas Bladder nodules can also be detected Assessment of tenderness, mobility versus fixation of organs Sliding sign- obliteration of POD if rectosigmoid doesn t slide freely against upper vagina and uterus 25
Pre-operative assessment - MRI MRI (magnetic resonance imaging) predicts 95% of deep endometriosis pre-operatively and assists in the planning of surgery. MRI needs to be reported by a radiologist with expertise in endometriosis. 26
Management overview Individualise treatment based on symptoms Depends on age, extent of disease, symptoms and future fertility expectations Medical Symptomatic management: NSAIDs, Ponstan, acupuncture, mindfulness Hormonal: menstrual suppression (not appropriate for infertility). Cyclical or continuous. OCP/Progesterone alone. GnRH, Danazol Failed medical treatment warrants surgery Surgical Excision versus ablation Staged surgery Pelvic clearance 27
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Surgical management of endometriosis Post medical treatment failure, patient request, stage 3/4 endometriosis, infertility Proper pre-operative assessment Conservative surgery with preservation of uterus and as much ovarian tissue if fertility is a concern Realistic expectations of patients- incurable condition and likely will require repeat surgery if symptoms return- 30% after 5 years Laparoscopy preferred technique Aims: treat all visible disease, conserve fertility, restore anatomy, prevent or delay recurrence 29
Impact on fertility and pregnancy Endometriosis in a large cohort study over 8000 women was associated with (SS): Miscarriage OR 2.44 Early pregnancy loss OR 2.62 Placenta praevia aor 2.24, PPH 1.30, LSCS 1.40 30
References NICE guidelines RANZCOG guidelines Novosure/Myosure website S Lyons. Endometriosis: essentials for general practice. Jean Hailes Foundation: Endometriosis WES Consensus RCOG 2016- Endometrial hyperplasia 31
32 Thank you!