Abnormal Uterine Bleeding

1. Abnormal Uterine Bleeding Emma Readman Gynaecologist, Endosurgeon Endosurgery Unit, MHW. Gynaecologist in Charge, Ambulatory Hysteroscopy, MHW

2. Abnormal Uterine Bleeding: More • Heavier than normal bleeding • Prolonged uterine bleeding >10days • Frequency < than 3 weeks • Intermenstrual spotting or bleeding • Post coital bleeding

3. Increased bleeding: pathogenesis • Structural Vs Functional • Structural –EXCLUDE PREGNANCY • IUDs • Polyps • Fibroids •  bleeding by endometrial surface area • 30% to 70% women have fibroids, • bleeding caused by those situated near or adjacent to endometrium, or that otherwise expand endometrial surface area Otherwise often ASYMPTOMATIC,COEXISTANT • Endometrial cancer • Endometrial hyperplasia

4. Menstrual cycle

5. Functional bleeding • Functional: • Ovulatory Vs Anovulatory • Ovulatory • loss of local endometrial haemostasis • Progesterone withdrawal mediated spiral artery vasoconstriction, modulated by prostaglandins (PG), decreased ratio therefore vasodilates

6. Menorrhagia: Pathogenesis • PGs also opposed by nitrous oxide • Other proteolytic enzymes • Anovulatory Bleeding: • Systemic in nature: hypothalamo-pituitary-ovarian axis • Also local haemostatic mechanisms rendered deficient

7. Menorrhagia: Pathogenesis • Also bleeding disorders:Von Willebrande’s Disease 10.7% in women with menorrhagia(US centres disease control and prevention) • Enhanced fibrinolysis

8. Clinical evaluation

9. Medical Options • Fe therapy • Antifibrinolytics • Cyclo-oxygenase inhibitors • Progestins • Continuous/cyclic • Local • Inplantable • Oestrogens plus progestins • Androgens • GNRH agonists and antagonists

10. Antifibrinolytics • Tranexamic acid 1g QID first 4 days cycle for ovulatory DUB • Virtually all cases bleeding reduces 40-60% • Placebo controlled trials show no incr GIT Ses (Cochrane review) • No evidence incr risk thromboembolic disease even if high risk (Lindoff ’93)

11. Cyclo-oxygenase inhibitors (NSAIDS) • Unclear exactly how work but likely generally reduce PGs locally, therefore vasoconstrict • 5/7 trials Cochrane showed mean menstrual blood loss decreased c/w placebo, 2/7 no change. • Trials usually used mefanamic acid(Ponstan) 250-500mg 2-4x daily, also naproxen and ibuprofen • Randomised trials comparing danazol & tranexamic acid to NSAIDS show both superior

12. Progestins: cyclic 10/7 • Most of world literature uses norethisterone • >= 50% with anovulatory DUB get regulated cycles with cyclical norethisterone, 10 days per month (luteal phase prog) • Women with ovulatory DUB unlikely benefit, may get worse • Cochrane says less effective than tranexamic acid, danazol, Mirena in ovulatory DUB if used 10/7 • using tranexamic acid better for general health, IMB and social and sexual functioning (c/w luteal phase prog)

13. Progestins: cyclic (long cycle) and continuous • Norethisterone 5mg TDS days 5-26 reduced menstrual vol by 87% • Only 22% were willing to continue therapy beyond 3/12, preferred IUD. • Continuous progesterone no published data with DUB

14. Progestins:Local • Mirena, 20mcg levonorgestrel daily 5 ys • Greatest impact on bleeding volume of any med treatment if ovulatory (94% decr blood vol at 3/12, 76% of women wanted to continue post 3/12) Not clear if anovulatory • IUD c/w hysteroscopic endometrial ablation by experts showed 79% decr Vs 89% at12/12, equivalent satisfaction • Scandinavian open trial with ovulatory DUB scheduled for hysterectomy, 64.3% elected to cancel op c/w 14.3% allocated to current med mx

15. Progestins: Implantable • Implanon (etonogestrel,3rd gen prog) 3 ys • Less bleeding, variable pattern • 30-40% cycles amenorrhoeic (c/w 51% Depo) • 30% infrequent bleeding (c/w 16% Depo) • 10-20% frequent or prolonged bleeding (c/w 35%) • Usually know within 3/12 what pattern will be but stabilises at 12/12

16. OCPs • Generally considered effective in Mx of both ovulatory and anovulatory • However, few available data to support • 1 RCT demonstrated 50% reduced flow(small sample size) • 1 RCT compared triphasic OPC & placebo anovulatory DUB 50% “much improved” vs 20%, with better life table scores • Nuvaring

17. GnRH and Danazol • Danazol >200mg daily, 50% individuals experience decrease menstrual vol,more effective than Ponstan • Ses mean usually not use • GNRH plus addback useful ovulatory and anovulatory, not licensed for this use Australia

18. Surgery • Hysteroscopic endometrial ablation • Laser not common usage-slow, costly, training issues • Electrical loop resection Vs ablation • Non-hysteroscopic endometrial ablation

19. Endometrial Ablation

20. Factors that effect outcome of HER/ablation • Better success women>45 • Surgeon experience • Adenomyosis worse outcome • In experienced hands, success rates larger uteri may be equiv to smaller uteri

21. Nonhysteroscopic endometrial ablation • Radiofrequency electrosurgical: • Vestablate • Novasure • Local hyperthermia: • Cavaterm • HydroThermAblator • Thermachoice • Cryotherapy • Microwave

22. Novasure

23. Randomised trials comparing HER/ablation & hysterectomy • 90% success, equal amenorhoea to hypomenorrhoea (multiple studies) • If retreat failures, 50% success • Cochrane shows greater patient satisfaction with hysterectomy • Shorter hospital stays, fewer complications, less cost and earlier return to normal in HEA • Reoperation rates in HEA increase steadily with time, only 1 trial 4 year follow up-40% reoperation rates

24. Alternative therapies • garlic • Panax ginseng • Chaste tree • Wild yam • Cramp bark • Helionas root

25. Alternative therapies • Garlic • Inhibits platelet aggregation in a dose dependent fashion • Increased fibrinolysis • Discontinue use 7 days prior to surgery • Advise against use if low platelets • Ginseng • Many different ginsenosides different effects • Steroidal saponins • Lower post prandial glucose • May irreversibly inhibit platelet aggregation • Stop ginseng 1 week prior to surgery

26. Case One • Mrs MM, a 24 year old has always had heavy periods, sexually active • Tried OCP, no success 30 and 50 mcg, • Wants children in the next few years

27. Case two • Mrs CC is a 43 year old, had 3 children LUSCS • Periods becoming increasingly heavy over last four years, now flooding, dysmenorrhoea • Needs contraception too

28. Case three • Ms PV is a 45 year old • Heavy irregular periods increasing over last 2 years • Some hot flushes