Primary Care Women’s Health Forum
16th June 2010
Abnormal uterine bleeding:The University Of Birmingham
T Justin Clark MD (Hons), MRCOG
Consultant Obstetrician and Gynaecologist Birmingham Women’s HospitalUnited Kingdom
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AUB
Overview
Modern management of abnormal uterine bleeding (‘AUB’)
Medical Management
Hysteroscopic surgery and fibroid management
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Primary Care Women’s Health Forum
16th June 2010
Modern management of AUBThe University Of Birmingham
T Justin Clark MD (Hons), MRCOG
Consultant Obstetrician and Gynaecologist Birmingham Women’s HospitalUnited Kingdom
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AUB
What is modern management?
Key features:Efficient, structured and ‘office’ based⌧Patient-care pathways
• Interface between primary and secondary care
⌧Diagnosis• ultrasound
⌧Treatment• Woman-centred; choice; minimally invasive
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AUB
Outpatient or ‘office’ procedure:Definition
Outpatient procedures are performed in an appropriate clinic setting, but without the need for formal operating theatre facilities or general anaesthesia.
These clinics are usually within a hospital outpatient department (an ‘outpatient hysteroscopy clinic’), but specific minor operative rooms, other multi-purpose facilities or primary care centres.
“True outpatient procedures” will be discharged unaccompanied within the allocated clinic time and do not require a formal recovery period in a hospital bed.
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AUB
Primary care setting?
Hospital based (secondary care)Inpatient Day caseDay case Office
This new paradigm has been driven by health technologies and enthusiasts
Primary care:Office Primary care(Office High street)
These concepts can be driven by infrastructure, government and enthusiasts
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AUB
Pelvic ultrasound
Justin Clark MD (Hons) MRCOG, Birmingham Women’s HospitalCOPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
AUB
Miniaturisation of endoscopes
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AUB
Mirena (LNG-IUS)
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AUB
Endometrial ablation
Various devicesTwo that I use in both the inpatient and outpatient setting
Justin Clark MD (Hons) MRCOGBirmingham Women’s Hospital
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AUB
Enthusiasts.........
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AUB
Primary care setting?
Hospital based (secondary care)Inpatient Day caseDay case Office
This new paradigm has been driven by health technologies and enthusiasts
Primary care:Office Primary care(Office High street)
These concepts can be driven by infrastructure, government and enthusiasts
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AUB
Change of outpatient treatment setting:Secondary to primary care???
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AUB
Change in philosophy
NHS Operational strategy“Diagnosis & Treatment Centres”
Justin Clark MD (Hons) MRCOG, Birmingham Women’s Hospital
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AUB
‘High Street’ Gynaecology??
Justin Clark MD (Hons) MRCOG, Birmingham Women’s HospitalCOPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
AUB
Responding to DoH- ‘Care Closer to home’
The Our health, our care, our say White Paper sets out a vision to provide people with good quality social care and NHS services in the communities where they live. NHS services are half way through a 10 year plan to become more responsive to patient needs….. ..and prevent ill health by the promotion of healthy lifestyles………. Give service users more independence, choice and control.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4127453
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AUB
Responding to DoH- Care Closer to home’
The Our health, our care, our say White Paper sets out a vision to provide people with good quality social care and NHS services in the communities where they live. NHS services are half way through a 10 year plan to become more responsive to patient needs….. ..and prevent ill health by the promotion of healthy lifestyles………. Give service users more independence, choice and control.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4127453
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AUB
Responding to DoH- the Darzi review of the NHS
To set us on the path to the next stage of the transformation of the NHS, the Prime Minister and I have asked Professor Sir Ara Darzi – one of the world’s leading surgeons - to carry out a wide-ranging review of the NHS. This is a once in a generation opportunity to ensure that a properly resourced NHS is clinically led, patient-centred and locally accountable.
Justin Clark MD (Hons) MRCOG, Birmingham Women’s HospitalCOPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
AUB
What is modern management?
Key features:Efficient, structured and ‘office’ based⌧Patient-care pathways
• Interface between primary and secondary care
⌧Diagnosis• ultrasound
⌧Treatment• Woman-centred; choice; minimally invasive
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AUB
Uniformly optimsing care
Clear, evidence-based pathwaysStandardised referral criteria⌧Audit compliance and patient outcomes
Requires:⌧‘Specialists within primary care
• ‘GPSIs’ / PCWHF• Nurse practitioners
⌧Lead clinician in secondary care
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AUB
What is modern management?
Key features:Efficient, structured and ‘office’ based⌧Patient-care pathways
• Interface between primary and secondary care
⌧Diagnosis• ultrasound
⌧Treatment• Woman-centred; choice; minimally invasive
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AUB
Conclusions
Office-based diagnosis and treatment
Standardised, evidence based care pathways between primary & secondary care
Utilisation of latest medical and surgical health technologies where evidence supports
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Primary Care Women’s Health Forum
16th June 2010
Medical management of AUBThe University Of Birmingham
T Justin Clark MD (Hons), MRCOG
Consultant Obstetrician and Gynaecologist Birmingham Women’s HospitalUnited Kingdom
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AUB
Up to date guidance
Justin Clark MD (Hons) MRCOG Justin Clark MD (Hons) MRCOG, Birmingham Women’s HospitalCOPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
Investigations
Justin Clark MD (Hons) MRCOG, Birmingham Women’s HospitalCOPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
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AUB
Pelvic ultrasound
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AUB
What investigations should I arrange in primary care?
Abnormal Uterine BleedingMenorrhagia⌧FBC⌧(Pelvic USS – DEPENDS UPON EXAMINATION FINDINGS)
IMB⌧(Pelvic USS – DEPENDS UPON EXAMINATION FINDINGS)⌧(Genital tract swabs)
PMB/HRT bleed⌧Pelvic USS
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Medical Management
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Incidence and prevalence of menorrhagia
Affects approximately 880,000 women in EnglandAnnual rate of women with heavy menstrual bleeding
presenting to services
0.67%
2.58%1.94% 1.73%
2.10%
2.96%
4.47%
5.40%
4.64%
0.00%
1.00%
2.00%
3.00%
4.00%
5.00%
6.00%
12 to14
15 to19
20 to24
25 to29
30 to34
35 to39
40 to44
45 to49
50 to51
Age range
Rat
e of
pre
sent
atio
n
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AUB
Likely causes of heavy menstrual bleeding
Common Less common Rare
Dysfunctional Uterine Bleeding
Ovular
Anovular (endometrial
hyperplasia)
Gynaecological disease
Endometriosis
Adenomyosis
Diffuse myometrial hypertrophy
Pelvic inflammatory disease
Intrauterine polyps
Gynaecological cancer
Uterus
Ovary (theca and granulosa cell tumours)
Fibroids
Submucous
Intramural
Pregnancy related
Retained products of conception
Endocrine
Thyroid dysfunction
Iatrogenic
Intrauterine contraceptive devices
Exogenous sex hormones
Anticoagulants
Haematological
von Willebrand’s disease
Idiopathic thrombocytopenia
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AUB
Common presentations:HEAVY REGULAR PERIODS
Likely diagnosis = ‘dysfunctional uterine bleeding’
TreatmentFirst-line⌧Non-hormonal
• TXA, MFA, (Iron)⌧Hormonal
• COC• Mirena
Second-line• Endometrial Ablation• Hysterectomy
Take home message = Regular menstruation is not associated with significant pathology but treatment is indicated on the impact symptoms have on HRQL
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AUB
Common presentations:HEAVY REGULAR PERIODS + FIBROIDS
In the presence of fibroids pharmacological treatments more likely to fail – earlier referral to secondary care for..........
Myomectomy⌧Hysteroscopic⌧Open⌧Radiological
• Uterine Artery Embolisation
Hysterectomy⌧Laparoscopic / Vaginal⌧Open
Take home message = Fibroids are common; symptoms more resistant to standard pharmacological treatments and endometrial ablation
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AUB
Common presentations:HEAVY IRREGULAR PERIODS
Likely diagnosis‘Dysfunctional uterine bleeding’Anovulation⌧Endometrial hyperplasia
TreatmentFirst-line⌧Hormonal
• COC• Mirena• Cyclical systemic progestins
Second-line• Endometrial Ablation• Hysterectomy
Take home message = Erratic menstruation requires hormonal or surgical management; further endometrial assessment (biopsy +/- hysteroscopy) is required if >45 years or obese
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AUB
Common presentations:HEAVY PERIODS IN TEENAGERS / YOUNG
Likely diagnosis‘Dysfunctional uterine bleeding’⌧ Anovulation
BUT CONSIDER HAEMATOLOGICAL PROBLEM⌧ Von Willebrand’s disease⌧ Platelet disorder
TreatmentFirst-line⌧ Hormonal
• COC +/- TXA/MFA• (Mirena)• (Cyclical systemic progestins)
Second-line• Haematologist / Desmopressin (Octim nasal spray)• Endometrial Ablation• Hysterectomy
Take home message = Consider clotting disorders in young women (bleeding history)
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AUB
Heavy Menstrual Bleeding:When is referral to secondary care warranted?
Symptoms refractory to medical treatment
Abnormal clinical examination• Abnormal cervix• Significant tenderness • Pelvic mass not thought to be fibroids• Significant fibroid uterus (palpable abdominally)
Lower threshold for referral if:Risk factors for endometrial hyperplasia
• Irregular periods, obesity, family history, >40 yearsSubstantial impact on health related quality of lifeAssociated iron deficiency anaemia
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AUB
Common presentations:INTERMENSTRUAL BLEEDING
Likely diagnosisEndometrium⌧Physiological (hormonal)⌧Dysfunctional uterine bleeding⌧Endometrial instability - ? Progestogen insufficiency⌧Endometrial polyp
Cervix⌧Cervical cancer rare (especially in women with normal smear history)⌧Cervical polyp⌧Lower genital tract infection
Treatment⌧Reassurance⌧COC⌧(Antibiotics)⌧(Cervical cautery)
Take home message = Examine cervix, check smear history, consider triple swabs & arrange a pelvic USS; Distinguish from irregular periods
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AUB
Intermenstrual Bleeding:When is referral to secondary care warranted?
Normal examinationPersistent symptoms (Anxiety)
Abnormal clinical examination• Abnormal cervix• Significant tenderness • Pelvic mass not thought to be fibroids
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AUB
Common presentations:POSTMENOPAUSAL BLEEDING
Likely diagnosis5-15% = Endometrial cancer / pre-cancer (atypical endometrial hyperplasia)85-95%= Benign pathology
• Atrophic changes to lower genital tract• Endometrial polyps
InvestigationPelvic examinationPelvic ultrasound (endometrial thickness)Outpatient endometrial biopsy +/- outpatient hysteroscopy
ManagementReassurance (50% +)Benign pathology⌧Outpatient hysteroscopy clinic – hysteroscopic polypectomy / myomectomy)⌧Local / systemic oestrogen
Malignant pathology⌧Oncology (hysterectomy/radiotherapy/chemotherapy)
Take home message = Arrange urgent referral via ‘PMB pathway’ for rapid pelvic ultrasoundJustin Clark MD (Hons) MRCOG, Birmingham Women’s HospitalCOPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
AUB
Post-menopausal Bleeding:When is referral to secondary care warranted?
Mandatory – urgent referral
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AUB
Common presentations:HRT RELATED BLEEDING
Likely diagnosis⌧Absorption – compliance / malabsorption⌧Cervical/Endometrial/Ovarian pathology
• Common– Endogenous ovarian activity (i.e ‘perimenopause’)– Endometrial pathology - Hyperplasia, Polyps, ‘Unstable’ atrophic endometrium
Investigation⌧Pelvic examination⌧Pelvic ultrasound (endometrial thickness)⌧Outpatient endometrial biopsy +/- outpatient hysteroscopy
Management⌧Pathology
• Polypectomy; systemic / local progestins (MirenaTM for hyperplasia) ⌧No pathology
• Review need for HRT• Change HRT preparation: Sequential – sequential; Sequential – continuous combined (‘no
bleed’) or vice-versa; ERT +Mirena
Take home message = Exclude gynaecological pathology (pelvic exam + arrange pelvic ultrasound) and review need for and type of HRT
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AUB
HRT Bleeding:When is referral to secondary care warranted?
Persistent symptomsDefinition?
Abnormal clinical examination• Abnormal cervix• Significant tenderness • Pelvic mass
Abnormal ultrasound scan Endometrial thickness >4mm
Lower threshold for referral if:Risk factors for endometrial hyperplasia / cancer
• Obesity• Family history• Substantial impact on health related quality of life
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Further Information
Justin Clark MD (Hons) MRCOG, Birmingham Women’s Hospital
•Diagnosis and Management of common gynae conditions
•PMB
•HRT & menopause
•Menorrhagia
•Outpatient hysteroscopic surgery -polyps, fibroids
•Mirena
•Essure sterilisation
•Outpatient endometrial ablation
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Conclusions
NICE guidance for HMBTranexamic acid, mefanamic acid, COC and MIRENA
PMB pathways based upon USS and locally organisedUniformity of approach needed⌧Audit of referral rates, treatments, hysterectomy rates,
outcomes, patient satisfaction
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Future developments:Abnormal uterine bleeding, fibroids, chronic pelvic pain & endometriosis
Justin Clark MD (Hons) MRCOG, Birmingham Women’s HospitalCOPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
Future developments:Abnormal uterine bleeding, fibroids, chronic pelvic pain & endometriosis
Justin Clark MD (Hons) MRCOG, Birmingham Women’s HospitalCOPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
Future developments:Abnormal uterine bleeding, fibroids, chronic pelvic pain & endometriosis
Justin Clark MD (Hons) MRCOG, Birmingham Women’s HospitalCOPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
Primary Care Women’s Health Forum
16th June 2010
Hysteroscopic surgery and fibroid mangement
The University Of Birmingham
T Justin Clark MD (Hons), MRCOG
Consultant Obstetrician and Gynaecologist Birmingham Women’s HospitalUnited Kingdom
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AUB
Routine hysterectomy?
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AUB
Examples: Old vs. New ApproachesUterine polyp
INPATIENT
Abnormal Uterine bleeding
Hysteroscopy / D&C under GA
OFFICE
Abnormal Uterine bleeding
Pelvic Ultrasound
Outpatient hysteroscopic polypectomy
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AUB
Examples: Old vs. New ApproachesSubmucous fibroid
INPATIENT
Abnormal Uterine bleeding
Hysteroscopy / D&C under GA
Reschedule for hysteroscopic resection under GA OR Hysterectomy
OFFICE
Abnormal Uterine bleeding
Pelvic Ultrasound
Outpatient hysteroscopic resection of fibroid OR scheduling for GA procedure (hysteroscopic resection OR hysterectomy)
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AUB
Fibroids: ManagementMedical
⌧TXA, MFA, progestogens, GnRH-a⌧MirenaTM
Surgical⌧Endometrial ablation
• Sound length<12cm
• Regular cavity (no distorting SMFs)⌧Myomectomy
• Hysteroscopic (+/- MirenaTM or endometrial ablation)• Laparoscopic• Open
⌧Hysterectomy
Radiological⌧Uterine Artery Embolisation⌧Other (under evaulation)
• MRI cryoablation; myolysis; USS guided injection; uterine arterial mechanical occlusion)
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AUB
Fibroids: ManagementMedical
⌧TXA, MFA, progestogens, GnRH-a⌧MirenaTM
Surgical⌧Endometrial ablation
• Sound length<12cm
• Regular cavity (no distorting SMFs)⌧Myomectomy
• Hysteroscopic (+/- MirenaTM or endometrial ablation)• Laparoscopic• Open
⌧Hysterectomy
Radiological⌧Uterine Artery Embolisation⌧Other (under evaulation)
• MRI cryoablation; myolysis; USS guided injection; uterine arterial mechanical occlusion)
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Examples: Old vs. New ApproachesEndometrial Ablation
INPATIENT
Abnormal Uterine bleeding
Hysteroscopy / D&C / Endometrial Ablation under GA (if suitable)
OFFICE
Abnormal Uterine bleeding
Pelvic Ultrasound + Outpatient Biopsy
Outpatient hysteroscopy with endometrial ablation
Justin Clark MD (Hons) MRCOG, Birmingham Women’s HospitalCOPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
Evidence for Office proceduresOutpatient hysteroscopic sterilisation:
Justin Clark MD (Hons) MRCOG, Birmingham Women’s HospitalCOPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
Evidence for Office proceduresOutpatient endometrial ablation:COAT Trial
THE COAT TRIALA RANDOMISED CONTROLLED TRIAL TO COMPARE
THE EFFECTIVENESS OF OUTPATIENTENDOMETRIAL ABLATION TECHNIQUES
(NOVASURETM VERSUS THERMACHOICETM III) IN THE TREATMENT OF MENORRHAGIA
Justin Clark MD (Hons) MRCOG, Birmingham Women’s Hospital
versus
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Evidence for Office ProceduresOUTPATIENT POLYP TREATMENT ‘OPT’ TRIAL
RCT comparing outpatient versus inpatient uterine polypectomy
Outcomes:EffectivenessAcceptabilityCosts
Multi-centre trial funded by the DoH Health Technology Assessment Programme (£1.1million)
Collaborating centres welcomeJoint authorship as part of collaborating groupBiannual collaborators meetingsPer patient paymentsOutpatient operative training
Contact:Mr Justin Clarkat Birmingham
Women’s Hospitalfor further
information
Phone:0121 6074712
Email:[email protected]
Justin Clark MD (Hons) MRCOG, Birmingham Women’s HospitalCOPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
Conclusions
Office or ‘ambulatory’ hysteroscopic surgery has allowed an efficient, one stop approach to managing intrauterine pathologies and dysfunctional uterine bleeding avoiding hospitaladmission
Fibroids are common and adversely impact upon the effectiveness of standard medical and minimally invasive treatments for AUB. Referral to secondary care is more likely tobe required.
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