Abnormal Uterine Bleeding
Emma ReadmanGynaecologist, EndosurgeonEndosurgery Unit, MHW.Gynaecologist in Charge, Ambulatory Hysteroscopy, MHW
Abnormal Uterine Bleeding: More
Heavier than normal bleeding Prolonged uterine bleeding >10days Frequency < than 3 weeks Intermenstrual spotting or bleeding Post coital bleeding
Increased bleeding: pathogenesis Structural Vs Functional Structural –EXCLUDE PREGNANCY
IUDs Polyps Fibroids
bleeding by endometrial surface area30% 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
Menstrual cycle
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
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
Menorrhagia: Pathogenesis Also bleeding disorders:Von
Willebrande’s Disease 10.7% in women with menorrhagia(US centres disease control and prevention)
Enhanced fibrinolysis
Clinical evaluation
Abnorm al b leeding
tria l o ftran exam ic ac id
N S A ID (esp if p a in )+ /- O C P
R eg u la r h eavyN U S , p ap , F B E
L H , F S H , TF Tsp ro lac tin , sen s tes t,
F A I, sh b gif lon g te rm , m ay n eed cu re tte
Irreg u la r h eavy
re fe rsp ec ia lis t
P C B /IM B /P M Bab N o f p ap , U S
exam in eU S , p ap , F B E
Medical Options Fe therapy Antifibrinolytics Cyclo-oxygenase inhibitors Progestins Continuous/cyclic Local Inplantable Oestrogens plus progestins Androgens GNRH agonists and antagonists
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)
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
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)
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
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% at 12/12, 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
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
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
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
Surgery
Hysteroscopic endometrial ablation Laser not common usage-slow,
costly, training issues Electrical loop resection Vs ablation Non-hysteroscopic endometrial
ablation
Endometrial Ablation
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
Nonhysteroscopic endometrial ablation
Radiofrequency electrosurgical: Vestablate Novasure
Local hyperthermia: Cavaterm HydroThermAblator Thermachoice
Cryotherapy Microwave
Novasure
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
Alternative therapies garlic Panax ginseng Chaste tree Wild yam Cramp bark Helionas root
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
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
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
Case three Ms PV is a 45 year old Heavy irregular periods increasing
over last 2 years Some hot flushes