Mr James Campbell FRCOG

1. Mr James Campbell FRCOG

2. Background - Menstrual disorders • 1 in 20 women aged 30-49 present to their GP per year • £ 7 million (!) is spent per year on primary care prescriptions • One of the most common reasons for specialist referral • Accounting for a third of gynaecological outpatient workload

3. Heavy menstrual bleeding (HMB) • Major impact on health-related quality of life • 22% of otherwise healthy women • Major problem in public health • significant cost • invasive treatments • 12% of all specialist referrals • Main presenting symptom for half of the hysterectomies performed in the UK Vessey M et al. The epidemiology of hysterectomy: findings of a large cohort study. Br J Obstet Gynaecol 1992; 99; 402-407.

4. Increasing prevalence • More periods per lifetime • Earlier menarche • Increased life expectancy • Ability to regulate fertility • Less time spent breastfeeding • More demanding lifestyles and reduced tolerance of troublesome periods

5. Menstruation Shedding of the superficial layers of the endometrium following the withdrawal of ovarian steroids

14. Normal menstruation • Menarche - 13 years • Menopause - 51 years • Regular cycles – 5 / 28 • Menstrual loss – 40ml (<80ml) • Pelvic discomfort

15. Menstrual disorders • Heavy menstrual bleeding (HMB) • Intermenstrual / Postcoital bleeding • Dysmenorrhoea = ‘painful periods’ • Premenstrual tension (PMT) • Post-menopausal bleeding • Oligo- or Amenorrhoea

16. HMB - Etiology • Endometrial origin • Increased fibrinolysis and prostaglandins • Uterine / pelvic pathology • Fibroids / Polyps • Pelvic infection (Chlamydia) • Endometrial or cervical malignancy • Medical disorders • Coagulopathy / Thyroid disease / Endocrine disorders • Iatrogenic (anti-coagulation / copper IUCDs)

17. Clinical evaluation & management Patient presenting with heavy menstrual bleeding

18. TAKE A HISTORY

19. Relevant history • Frequency and intensity of bleeding – Menstrual diary • Pelvic pain / Pressure symptoms • Abnormal vaginal discharge • Sexual and contraceptive history • Obstetric history • Smear history • History of coagulation disorder

20. Examination • Clinical examination • General appearance (? Pallor) • Abdominal examination (?Pelvic mass) • Speculum examination • Assess vulva, vagina and cervix • Bimanual examination • Elicit tenderness • Elicit uterine / adnexal enlargement

21. Investigations • Indicated if age > 40 years or failed medical treatment • FBC / Coagulation screen • Thyroid function (only if clinically indicated) • Smear / Endocervical swabs / High vaginal swabs • Pelvic ultrasound (USS) • Saline hysterosonography (?Polyps) • Hysteroscopy • Endometrial biopsy (Pipelle / D&C)

22. Hysteroscopy

23. Endometrial biopsy

24. Endometrial HyperplasiaWHO Classification • Simple hyperplasia No risk of malignant transformation • Complex hyperplasia Low risk (~5%) • Simple atypical hyperplasia Unknown risk • Complex atypical hyperplasia Significant risk (at least 30%)

25. Endometrium: simple hyperplasia

26. Complex non-atypical hyperplasia

27. Complex atypical hyperplasia

28. Causes of HMB

29. Endometrial origin “Dysfunctional uterine bleeding”

30. Anovulatory CyclesReasons for heavy menstrual bleeding • Endometrium develops • under the influence of oestrogen • Corpus luteum fails to develop • absence of progesterone • Spiral arteries do not develop properly and are unable to undergo vasoconstriction at the time of shedding • Endometrium supplied by thin-walled vessels • Result – prolonged heavy bleeding

32. Persistent Anovulation • Infertility • Endometrial hyperplasia • Increased risk of endometrial carcinoma

33. Management of HMB • Anti-fibrinolytics • Tranexamic acid (Cyclokapron®) • Prostaglandin synthetase inhibitor • Mefenamic acid (Ponstan®) • Combined oral contraceptive pill (COC) • Progestogens • GnRH analogues • Endometrial ablation • Hysterectomy

34. Management - Progestogens • Luteal phase progestogens (only useful if anovulatory) • Long-acting progestogens (Depoprovera / Implanon) • Mirena IUS

35. Mirena IUS

36. Endometrial ablation • Day-case procedure or out-patient setting • 1st generation • Trans-cervical resection • 2nd generation • Thermal balloon • Microwave • Impedance controlled • Similar outcome to Mirena IUS

37. Hysterectomy • “Treatment of choice for cancer, but a choice of treatment for menorrhagia” Lilford RJ (1997) BMJ 314; 160 - 161 • Surgical access • Total versus subtotal hysterectomy • Removal versus conservation of ovaries and use of HRT

38. Abdominal hysterectomy Vaginal hysterectomy

39. Uterine pathology Evaluation & Management Polyps and Fibroids

40. Endometrial polyps • Localised overgrowths of endometrium projecting into uterine cavity • Common in peri- and postmenopausal women (10 – 24% of women undergoing hysterectomy) • Account for 25% of abnormal bleeding in both pre- and postmenopausal women • Typically benign, but malignant change can rarely occur • Non-neoplastic lesions of endometrium containing glands, stroma and thick-walled vessels • Glands may be inactive, functional or hyperplastic • Association with tamoxifen use

41. Endometrial Polyp

42. Endometrial polyps • Diagnosis • Pelvic USS / Saline hysterosonography • Hysteroscopy • Management • Operative removal with polyp forceps / curette or hysteroscopic resection

43. Uterine Fibroids(Leiomyomata) • Occur in 20 – 30% of women over 30 years • Usually multiple • Almost invariably benign • Variable sizes, up to 20 cm or more • Sex steroid-dependent – regress after the menopause

45. Submucosal uterine fibroid

47. Leiomyoma with central degeneration

48. Leiomyoma

49. Uterine fibroids • Symptoms • 50% asymptomatic • HMB / Dysmenorrhoea • Pressure effects • Infertility • Pregnancy complications • Diagnosis • Clinically enlarged uterus • Pelvic USS • Hysteroscopy / Laparoscopy

50. Uterine fibroids - Management • Conservative • Ensure Dx of fibroids and R/O adnexal mass • Medical • Tranexamic acid / NSAIDs • Mirena IUS • GnRH agonists • Surgical • Myomectomy (hysteroscopic / laparascopic / by laparotomy) • Hysterectomy • Uterine artery embolization