Mr James Campbell FRCOG

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

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 UKVessey M et al. The epidemiology of hysterectomy: findings of a large cohort study. Br J Obstet Gynaecol 1992; 99; 402-407.

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

Menstruation

Shedding of the superficial layers

of the endometrium

following the withdrawal

of ovarian steroids

Normal menstruation

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

Menstrual disorders

Heavy menstrual bleeding (HMB)

Intermenstrual / Postcoital bleeding Dysmenorrhoea = ‘painful periods’ Premenstrual tension (PMT) Post-menopausal bleeding Oligo- or Amenorrhoea

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)

Clinical evaluation & management

Patient presenting

with

heavy menstrual bleeding

TAKE A HISTORY

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

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

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)

Hysteroscopy

Endometrial biopsy

Endometrial HyperplasiaWHO Classification

Simple hyperplasiaNo risk of malignant transformation

Complex hyperplasia

Low risk (~5%)

Simple atypical hyperplasia

Unknown risk

Complex atypical hyperplasiaSignificant risk (at least 30%)

Endometrium: simple hyperplasia

Complex non-atypical hyperplasia

Complex atypical hyperplasia

Causes of HMB

Endometrial origin “Dysfunctional uterine bleeding”

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

Persistent Anovulation

Infertility Endometrial hyperplasia Increased risk of endometrial carcinoma

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

Management - Progestogens

Luteal phase progestogens

(only useful if anovulatory) Long-acting progestogens

(Depoprovera / Implanon) Mirena IUS

Mirena IUS

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

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

Abdominal hysterectomy

Vaginal hysterectomy

Uterine pathology

Evaluation & Management

Polyps and Fibroids

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

Endometrial Polyp

Endometrial polyps

Diagnosis Pelvic USS / Saline hysterosonography Hysteroscopy

Management Operative removal with polyp forceps / curette

or hysteroscopic resection

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

Submucosal uterine fibroid

Leiomyoma with central degeneration

Leiomyoma

Uterine fibroids

Symptoms 50% asymptomatic HMB / Dysmenorrhoea Pressure effects Infertility Pregnancy complications

Diagnosis Clinically enlarged uterus Pelvic USS Hysteroscopy / Laparoscopy

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

Postmenopausal bleeding

Evaluation

Postmenopausal bleeding (PMB)

ALL WOMEN WITH PMB

MUST BE INVESTIGATED Purpose of investigation:

Exclude malignancy of endometrium and cervix

Endometrial Ca in up to 4% of women with PMB Precursors of endometrial Ca

(complex hyperplasia +/- atypia)

PMB – Exclude malignancy

History and assessment of risk factors Use of HRT / Tamoxifen / BMI / Family Hx

Clinical Examination (!) R/O cervical carcinoma

Trans-vaginal USS Assessment of endometrial thickness (<3mm)

Endometrial sampling (+/- uterine evaluation) Treatment for endometrial Ca

Hysterectomy +/- radiotherapy

Endometrial Carcinoma

Type I Oestrogen dependent 80% Low grade Endometrioid histology Assoc with obesity (40%), nulliparity, late menopause, tamoxifen

Type II Non-oestrogen dependent Older postmenopausal women High grade Serous, clear cell and mixed histology Tamoxifen; no association with hyperoestrogenism or hyperplasia Aggressive behaviour

Endometrioid carcinoma

Endometrioid Carcinoma

Endometrial CarcinomaPrognostic Factors

Histological type Histological grade Depth of myometrial invasion Lymphovascular space invasion FIGO stage

Case 1 43 year old, para 2 + 0, company executive

Presenting complaint excessive menstrual blood loss requirement for contraception

History Menarche aged 13 years Used OC pill until 35 years Smokes 15 / day

Examination Normal sized uterus and normal adnexae

Case 2 38 year old, para 0 + 0, primary school teacher

Presenting complaint excessive menstrual blood loss and dysmenorrhoea

History Menarche aged 12 years Used OC pill until 25 years Currently using tranexamic acid with unsatisfactory effect

Examination Uterus appears enlarged to 18/40 size

Case 3

59 year old, para 0 + 0, retired

Presenting complaint vaginal bleeding on two occasions over last 3 months

History Menopause aged 49 years Polycystic ovarian syndrome Infertility BMI = 38 / Overweight for many years

How would you evaluate this case?

Would you carry out any investigations?

What management options would you discuss and recommend?