Management of Menorrhagia

Christine Putri, Nick Harper, Chris Brookes

Menorrhagia• NICE Definition:

“excessive menstrual blood loss which interferes with the woman’s physical, emotional, social and material quality of life, and which can occur alone or in combination with other symptoms. Any interventions should aim to improve quality of life measures.”

>80ml per cycle

Epidemiology

33% of woman complain of heavy periods

Prevalence 8–27% – subjective 11-26% - objective

Causes

• Dysfunctional uterine bleeding

• IUCD• Fibroids• Endometriosis• Adenomyosis• Pelvic infection• Polyps

• Endometrial carcinoma• Anticoagulation therapy• Hypothyroidism• Blood dyscrasia

• RCT, n=638 with undertaken in the UK on women with menorrhagia (Critchley et al, 2001)

• <40 yr group: 11.5% endometrial/uterine polyps, 36% uterine fibroids, 1% endometrial cancer and 1% had hyperplasia

• >40 group: 6% endometrial/uterine polyps, 19% uterine fibroids

Dysfunctional Uterine Bleeding

• 80% of women treated for heavy menstrual bleeding have no anatomical pathology (Lethaby et al, 2008)

• Absence of pelvic pathology

• menarche and perimenopause

• Ovulatory(10%) or unovulatory(90%)

Fibroids

• Benign smooth muscle tumour (leiomyomas)• Common, 20% of women• Oestrogen-dependent

• Presentation: – menorrhagia, – fertility problems, – pain, – mass

Endometrial Polyps

• growth of the lining of the uterus

• Presentation: • asymptomatic, irregular

bleeding, IMB, PMB, menorrhagia

History

• Nature of bleeding

• Symptoms suggesting possible significant

pathology

• Other features that may determine treatment

or other action

Examination

• General observation

• Abdominal examination

• Pelvic examination (+/- swabs)

Investigations

• FBC, ferritinin: anemia

• TFT, coagulation: to exclude systemic cause

• TVS: To exclude local organic causes

• Endometrial biopsy (at hysteroscopy or with a

pipelle)

• Hysteroscopy: visualize uterine cavity

Measurement of blood loss

• Direct measurement of MBL – alkaline haematin

• Indirect measurement of MBL – pictorial blood

loss assessment charts (PBAC)

• Surrogate and self-assessment measures of MBL

Methods of Management

1

Pharmaceutical treatment• Combined OCP

• Antifibrinolytics– Tranexamic acid

• NSAIDS– Mefenamic acid

• Oral progestogens– Norethisterone

•821,700 prescriptions

•£7,176,5952

• Progestogen - Progestin - Levonorgestrel• Mirena (Bayer)

• Contraception

• Primary menorrhagia

• Endometrial hyperplasia

Intrauterine System (IUS)

3

Intrauterine System (IUS)

• Local effects

• Thickening of cervical mucus

• Suppression of ovulation

• Prevention of endometrial proliferation

4

Intrauterine System (IUS)

• Ectopic (50%)• PID• Irregular bleeding/spotting• Embedment• Perforation• Expulsion• Sepsis

5

Pharmaceutical treatment - NICE

• No structural/histological abnormality

1.Mirena2.Tranexamic acid/NSAIDs/cOCP3.Norethiserone (days 5-26)

• Try 2nd treatment if no improvement after 3 menstrual cycles

6

Endometrial destruction

• Endometrium + superficial myometrium

• Infertility?

1. Direct hysteroscopic vision

2. Non hysteroscopic vision

7

Direct Hysteroscopic vision

Laser photovapourisation

Laser Photovapourisation8

Direct Hysteroscopic vision

Laser photovapourisation Rollerball ablation

Rollerball ablation9

Direct Hysteroscopic vision

Laser photovapourisation Endometrial excisionRollerball ablation

Endometrial excision10

Direct Hysteroscopic vision

Laser photovapourisation

Bipolar radiofrequency

Endometrial excisionRollerball ablation

Bipolar radiofrequency11

Direct Hysteroscopic vision

Laser photovapourisation

Hydrothermal ablation

Bipolar radiofrequency

Endometrial excisionRollerball ablation

Hydrothermal ablation

12

Non Hysteroscopic vision

Microwave ablation

Microwave ablation

13

CryoablationMicrowave ablation

Non Hysteroscopic vision

Cryoablation

14

CryoablationMicrowave ablation

Heated balloon system

Non Hysteroscopic vision

Heated balloon system

15

Endometrial ablation - NICE

• 10,000 cases (‘93-94)• Complication rate 4.4%• Vaginal discharge, Cramping

• Initial treatment only after discussion• Avoid subsequent pregnancy• Any second generation method (cheapest)

16

Hysterectomy – 100% success!!!

• Abdominal• Vaginal• Laparoscopic

• Size• Mobility• Fibroids

17

18

Hysterectomy

• 60% of GP referrals for HMB – Hysterectomy

• 24,355 in 1993 • 10,559 in 2002

• Over 95% satisfaction rate after 3 years

• Up to 67% experience complication– Haemorrhage, damage to abdo. organs

19

Hysterectomy - NICE

• Not 1st line treatment• Pros/cons/risks

1.Vaginal (fewer complications)2.Abdominal

Total or Subtotal – shared choice

20

Evidence Base

Pharmacological intervention - Oral contraceptive pill

•Farquhar, C. and Brown, J., 2009, Oral contraceptive pill for heavy menstrual bleeding

•Only one trial of 45 fit criteria

•No significant difference between OCP, mefenamic acid, low dose danzol or naproxen

•Review unable to achieve objectives

• Lethaby, A et al, 2009, Antifibrinolytics for heavy menstrual bleeding.

• Four of fifteen trials that met criteria were used in meta-analysis

• Significant reduction compared to placebo -94.0 (95% CI: -146.5 to -73.8)

• Comparisons with mefenamic acid, norethisterone in luteal phase and etamsylate all produced a significant reduction in blood loss.

• -73 (95% CI: -123.4 to -22.6), -111.0 (95% CI: -178.5 to – 43.5) and -100 (95% CI: -143.9 to -56.1)

Pharmacological intervention - Antifibrinolytics

• Lethaby, A. et al, 2009, Nonsteroidal anti-inflammatory drugs for heavy menstrual bleeding

• Nine of seventeen selected trials were included

• NSAIDS were more effective than placebo at reducing bleeding

• Less effective than tranexamic acid, danazol and the levonorgestrel intrauterine system

• No significant differences between NSAIDS and other medical treatments

Pharmacological intervention - NSAIDS

• Lethaby, A. Et al, 2009, Cyclical progestogens for heavy menstrual bleeding

• Seven randomised trials that were selected included

• No comparison with placebo

• Significantly less effective than tranexamic acid, danazol and levonorgestrel IUS

Pharmacological intervention – Oral progestogens

• Lethaby et al, 2009, Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding

• Nine trials were selected and incorporated

• LNG IUS significantly reduced blood loss compared with luteal progestogens

• Endometrial ablation compared favourably with LNG IUS

• -45.2 units (95% CI: -56.9 to -33.5), but similar patient satisfaction

Pharmacological intervention – Levonoregestrel IUS (LNG IUS)

• Lethaby, A. et al, 2009, Endometrial resection / ablation techniques for heavy menstrual bleeding

• No significant difference between hysteroscopic and blind ablation

• Significant advantage of hysterectomy when compared with ablation

• Ablation cheaper in short term but narrows over longer term

• Hysterectomy stops all bleeding

Surgical intervention

• Majoribanks J, et al, 2010, Surgery versus medical therapy for heavy menstrual bleeding

• Twelve trials met criteria and were included

• 58% of those randomised to medical treatment had received surgery by 2 years

Medical vs. surgical

• Compared to oral medication endometrial resection significantly more effective NNT = 2, one study

• Conservative surgery significantly more effective than LNG-IUS at one year

• Two small studies favoured LNG IUS or found no difference – skewed data, loss to follow up

• No difference in satisfaction rates between LNG IUS and surgery

Pharmacological intervention – Medical vs. surgical

SummaryTreatment Reduction in

blood loss (%)Notes

Combined oral contraceptive pill

43 Contraceptive, little evidence base, weight change etc.

Tranexamic acid 29–58 Well tolerated. Do not improve dysmenorrhea

NSAIDs 20–49 Only taken during menstruation. GI side effects

oral progestogen* 83 Weight change, nausea, headache, bloating

Levonorgestrel IUS (Mirena)

71–94 Contraceptive, irregular bleeding, ectopics

Endometrial ablation 10% amenorrhea90% sig.

reduction

Infertility? All methods similar, go for cheapest.

Hysterectomy 100 Infertility

References• Farquhar, C. & Brown, J. (2009) Cochrane Review – Oral contraceptive pill for heavy menstrual

bleeding.• Lethaby, A., Irvine, G. & Farquhar, C. (2010) Cochrane Review – Cyclical progestogens for heavy

menstrual bleeding.• Majoribanks, J., Lethaby, A. & Farquhar. (2010) Surgery versus medical therapy for heavy

menstrual bleeding.• Lethaby, A., Hickey, M., Garry, R. & Penninx, J. (2009) Cochrane Review – Endometrial

resection/ablation techniques for heavy menstrual bleeding• Lethaby, A., Shepperd, S., Farquhar, C & Cooke, I. (2009) Ecochrane Review – Endometrial

resev=ction versus hysterectomy for heavy menstrual bleeding• Lethaby, A., Farquhar, C. & Cooke, I. (2009) Cochrane Review – Antifibrinolytics for heavy

menstrual bleeding.• Lethaby, A., Augood, C., Duckitt, K. & Farquhar, C. (2009) Cochrane Review – Nonsteroidal anti-

inflammatory drugs for heavy menstrual bleeding• Lethaby, A., Ivanova, V. & Johnson, N. (2009) Total versus subtotal hysterectomy for benign

gynaecological conditions• NICE – Heavy menstrual bleeding