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Management of menorrhagia
- 1. Management of Menorrhagia ChristinePutri, Nick Harper, Chris Brookes
- 2. Menorrhagia • NICE Definition: “excessivemenstrual 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
- 3. Epidemiology 33% of womancomplain of heavy periods Prevalence 8–27% – subjective 11-26% - objective
- 4. Causes • Dysfunctional uterine bleeding •IUCD • Fibroids • Endometriosis • Adenomyosis • Pelvic infection • Polyps • Endometrial carcinoma • Anticoagulation therapy • Hypothyroidism • Blood dyscrasia
- 5. • RCT, n=638with 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
- 6. 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%)
- 7. Fibroids • Benign smoothmuscle tumour (leiomyomas) • Common, 20% of women • Oestrogen-dependent • Presentation: – menorrhagia, – fertility problems, – pain, – mass
- 9. Endometrial Polyps • growthof the lining of the uterus • Presentation: • asymptomatic, irregular bleeding, IMB, PMB, menorrhagia
- 10. History • Nature ofbleeding • Symptoms suggesting possible significant pathology • Other features that may determine treatment or other action
- 11. Examination • General observation •Abdominal examination • Pelvic examination (+/- swabs)
- 12. 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
- 13. Measurement of bloodloss • Direct measurement of MBL – alkaline haematin • Indirect measurement of MBL – pictorial blood loss assessment charts (PBAC) • Surrogate and self-assessment measures of MBL
- 18.
- 19. Pharmaceutical treatment • CombinedOCP • Antifibrinolytics – Tranexamic acid • NSAIDS – Mefenamic acid • Oral progestogens – Norethisterone •821,700 prescriptions •£7,176,595 2
- 20. • Progestogen -Progestin - Levonorgestrel • Mirena (Bayer) • Contraception • Primary menorrhagia • Endometrial hyperplasia Intrauterine System (IUS) 3
- 21. Intrauterine System (IUS) •Local effects • Thickening of cervical mucus • Suppression of ovulation • Prevention of endometrial proliferation 4
- 22. Intrauterine System (IUS) •Ectopic (50%) • PID • Irregular bleeding/spotting • Embedment • Perforation • Expulsion • Sepsis 5
- 23. Pharmaceutical treatment -NICE • No structural/histological abnormality 1.Mirena 2.Tranexamic acid/NSAIDs/cOCP 3.Norethiserone (days 5-26) • Try 2nd treatment if no improvement after 3 menstrual cycles 6
- 24. Endometrial destruction • Endometrium+ superficial myometrium • Infertility? 1. Direct hysteroscopic vision 2. Non hysteroscopic vision 7
- 25. Direct Hysteroscopic vision Laserphotovapourisation Laser Photovapourisation8
- 26. Direct Hysteroscopic vision Laserphotovapourisation Rollerball ablation Rollerball ablation9
- 27. Direct Hysteroscopic vision Laserphotovapourisation Endometrial excisionRollerball ablation Endometrial excision10
- 28. Direct Hysteroscopic vision Laserphotovapourisation Bipolar radiofrequency Endometrial excisionRollerball ablation Bipolar radiofrequency11
- 29. Direct Hysteroscopic vision Laserphotovapourisation Hydrothermal ablation Bipolar radiofrequency Endometrial excisionRollerball ablation Hydrothermal ablation 12
- 30.
- 31.
- 32. CryoablationMicrowave ablation Heated balloon system Non Hysteroscopicvision Heated balloon system 15
- 33. 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
- 34. Hysterectomy – 100%success!!! • Abdominal • Vaginal • Laparoscopic • Size • Mobility • Fibroids 17
- 35.
- 36. Hysterectomy • 60% ofGP 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
- 37. Hysterectomy - NICE •Not 1st line treatment • Pros/cons/risks 1.Vaginal (fewer complications) 2.Abdominal Total or Subtotal – shared choice 20
- 38.
- 39. 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
- 40. • Lethaby, Aet 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
- 41. • 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
- 42. • 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
- 43. • Lethaby etal, 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)
- 44. • 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
- 45. • 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
- 46. • Compared tooral 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
- 47. Summary Treatment Reduction in bloodloss (%) 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% amenorrhea 90% sig. reduction Infertility? All methods similar, go for cheapest. Hysterectomy 100 Infertility
- 48. 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
Editor's Notes
- #3 1. Normal loss is about 35-40 ml monthly Menorrhagia is very subjective; a more practical definition may be that it is menstrual loss that is greater than the woman feels she can reasonably manage. Menorrhagia is menstrual blood loss which interferes with the woman&apos;s physical, emotional, social, and material quality of life, and which can occur alone or in combination with other symptoms n one study, over half the women referred for endometrial ablation complaining of heavy periods had menstrual blood losses of less than 80 mL. 3 Social embarrassment, inconven ience, costs of sanitary protection, the safety of using tampons, and interference with sexual activity all make coping with menstruation difficult. Heavy menstrual bleeding (HMB) should be recognised as having a major impact on a woman&apos;s quality of life, and any intervention should aim to improve this rather than focusing on menstrual blood loss.
- #4 33% of women describe their periods as heavy, most do not seek help. 1 in 20 women aged 30 to 49 years consult their GP each year for heavy periods and menstrual disorders. It is the second commonest gynaecological condition to be referred to hospital, accounting for 12% of all gynaecological referrals. Heavy menstrual bleeding accounts for 12% of all gynaecology referrals in the UK. Pitkin J; Dysfunctional uterine bleeding. BMJ. 2007 May 26;334(7603):1110-1. Harlow SD, Campbell OMR. Epidemiology of menstrual disorders in developing countries: A systematic review. BJOG: an International Journal of Obstetrics and Gynaecology 2004;111(1):6–16.
- #5 Blood dyscrasias: von willebrand:von Willebrand disease (vWD) is the most common hereditary coagulation abnormality described in humans, although it can also be acquired as a result of other medical conditions. It arises from a qualitative or quantitative deficiency of von Willebrand factor (vWF), a multimeric protein that is required for platelet adhesion. 40 to 60% of those who complain of excessive bleeding have no pathology and this is called dysfunctional uterine bleeding.20% of cases are associated with anovulatory cycles and these are most common at the extremes of reproductive life.Local causes include:Fibroids.Pelvic inflammatory disease.Carcinoma, especially endometrial carcinoma in women over 40; this usually presents with postmenopausal bleeding, but 20 to 25% of cases present with abnormalities of the menstrual cycle.Systemic disease can include hypothyroidism and bleeding disorders.An intra-uterine contraceptive device (IUCD) will increase menstrual flow and it has been claimed that sterilisation operations also increase loss. Prior to the operation women may have been taking oral contraceptives and, in comparison, they make periods artificially light. Further studies have found that sterilisation does not increase menstrual loss.2 Systemic disease: hypothyroidism, liver disease, obesity, polycystic ovarian syndrome (PCOS), haematological disorders
- #6 Critchley HO, Warner P, Lee AJ, et al. Evaluation of abnormal uterine bleeding: comparison of three outpatient procedures within cohorts defined by age and menopausal status. Health Technology Assessment 2001;8:(34)iii–iv,1–139.
- #7 Diagnosis must be made by exclusion, since organic pathology must first be ruled out Periods soon after the onset of menstruation in girls (the menarche) and just before menopause may in some women be particularly heavy. Hormonal disorders involving the ovaries-pituitary-hypothalamus (the &apos;ovarian endocrine axis&apos;) account for many cases, and hormonal-based treatments may regulate effectively. 10% of cases occur in women who are ovulating, but progesterone secretion is prolonged because estrogen levels are low. This causes irregular shedding of the uterine lining and break-through bleeding. Some evidence has associated Ovulatory DUB with more fragile blood vessels in the uterus. The lining of the uterus builds up naturally under the hormonal effects of pregnancy, and an early spontaneous miscarriage may be mistaken for a heavier than normal period. As women age and move towards menopause, ovulation is delayed and the remaining follicles in the ovaries become resistant to GnRH ( Gonadotropin releasing hormone )secreted by the hypothalamus gland in the brain. Either that or they don&apos;t develop an egg, and thus no progesterone is produced. Without progesterone, the estrogen is &quot;unopposed&quot; and keeps building up the lining of the uterus. During a woman&apos;s period, the endometrial lining which is normally shed never gets the signal to stop thickening. It keeps growing and sheds irregularly. Due to the extra thickness, the bleeding is unusually heavy. Less frequently in this age group, too little estrogen causes the irregular bleeding. Most cases of hemorrhagic are due to normal hormonal changes preceding menopause. Lethaby A, Irvine G, Cameron I; Cyclical progestogens for heavy menstrual bleeding. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD001016. [abstract]
- #11 The GDG identified three main areas of questioning. Nature of bleeding Initially the clinician should establish that the woman has menstrual bleeding that is, in her and the clinician’s opinion, heavy. 32 Heavy menstrual bleeding While non-menstrual bleeding is outside the scope of this guideline, epidemiological evidence suggests that an alteration in the menstrual cycle, intermenstrual bleeding or post-coital bleeding may be the first symptoms of gynaecological cancer and indicate the need for a pelvic examination. 95 Persistent intermenstrual bleeding requires investigation to exclude malignancy.95 Symptoms suggesting possible significant pathology The GDG felt that pelvic pain and pressure effects should be investigated, as these may indicate the presence of uterine pathology or disorders. Other features that may determine treatment or other action It is important for the clinician to explore the woman’s perspective. By exploring the woman’s ideas, concerns and expectations regarding HMB and its treatment, the requirements of therapy, education and reassurance may be determined. In addition, the clinician should elicit details of what treatment the woman has already undergone, if any. In addition, the GDG felt that issues such as age, an up-to-date smear test, family history of pathology, and future fertility and contraception plans should be ascertained.
- #12 General obs: Note general appearance and BMI. Body fat is very important in relation to metabolism of steroid hormones. Note any signs suggestive of endocrine abnormality or bruising. Look at the tongue for pallor and the nails for koilonychia. Anaemia is common; pallor (pale skin, mucosal linings and nail beds) but this is not a reliable sign. Irregular enlargement of uterus suggests fibroids; tenderness with or without enlargement suggest adenomyosis. Ovarian mass might be felt. Tenderness and immobile pelvic organs are common with infection and endometriosis.
- #13 Ferritin is a ubiquitous intracellular protein that stores iron and releases it in a controlled fashion. The protein is produced by almost all living organisms, including bacteria, algae and higher plants, and animals. In humans, it acts as a buffer against iron deficiency and iron overload.[3] If the ferritin level is low, there is a risk for lack of iron, which could lead to anemia Tvs: will assess endometrial thickness, detect fibroids, ovarian mass, detect larger intrauterine polyps Endo biopsy: if woman is &gt;40 with recent onset of menorrhea, ass w/ imb or has not responded to tx. To exclude endometrial malignanacy Hysteroscopy: polyps or fibroids that could be resected Pipelle:To make a diagnosis of, or exclude malignancy and premalignancy, it is necessary to obtain an endometrial biopsy for histological examination
- #14 Evidence from six diagnostic studies shows that the estimation of MBL from sanitary material using the alkaline haematin test is an accurate and precise method Given that sanitary product recovery methods may have limited use in clinical practice, other methods have been developed. These methods focus on indirect measures or self-assessment. Measuring menstrual blood loss either directly (alkaline haematin) or indirectly (‘pictorial blood loss assessment chart’) is not routinely recommended for HMB. Whether menstrual blood loss is a problem should be determined not by measuring blood loss but by the woman herself. [D(GPP)]
- #16 Endometrial polyps
- #17 Indications for useEndometrial biopsy should be considered in the following women:All women aged &gt;40 years with abnormal bleeding.Younger women with risk factors for endometrial cancer:Nulliparity (pregnancy protects against endometrial carcinoma by interrupting the continued stimulation of the endometrium by oestrogen)Family history of endometrial or colonic cancerA history of abnormal smearsObesityPolycystic ovary syndromeTamoxifen therapyUnopposed oestrogen therapyYounger women in whom abnormal bleeding does not resolve with medical treatment. Procedure: Bimanual examination to assess the size and position of the uterus.The cervix is visualised using a vaginal speculum and cleaned.Recent research has looked at transcervical instillation of 5 mls 2% lignocaine. This was shown significantly to reduce pain during endometrial sampling.2A tenaculum applied to the anterior lip of the cervix is used to provide gentle traction whilst a sound is inserted though the cervical os. This reduces the risk of uterine perforation. The tenaculum should be used to straighten the uterocervical canal, thereby preventing the pipelle from passing through the thin walled posterior vaginal wall.Dilators may be required if there is difficulty in passing the sound.When the position and size of the uterine cavity have been assessed, the pipelle is inserted through the cervical os and advanced until gentle resistance is felt.The inner piston of the device is then withdrawn to create suction and the endometrial sample is obtained by moving the pipelle up and down within the uterine cavity by approximately 2-3 cm but not beyond the cervical os. As the cannula is rotated during removal, a strip of endometrium is peeled off and sucked into the syringe.This procedure should be repeated at least four times and the device rotated 360 degrees to ensure adequate coverage of the area.The pipelle is then withdrawn from the cervical os and the endometrial sample expelled into a solution of formalin for transport to the laboratory.
- #20 Antifibrinolytics - Inhibits plasminogen activation. Stops fibrinolysis. Contraindication – thromboembolic disease Oral progestogens - Imbalance between oestrogen and progesterone. Too much oestrogen, lots of endometrium. Possibly anovulatory cycles Weight change, nausea, headache, dizziness, insomnia, loss of libido, bloating… Cost in 1995
- #21 Progesterone or progestogen-releas- ing intrauterine systems (PPRIUS) were initially introduced in an effort to reduce IUCD expulsion, by the addition of ’uterine- relaxing hormones’ Found that it caused a significant reduction in menstrual blood loss. Mirena is only currently available Endometrial hyperplasia – estrogen replacement therapy
- #23 Half of pregnancies that occur with mirena are ectopic Mirena cant be used in people with PID & also itself is associated with higher risk of PID
- #24 Use hormonal based if acceptable. If not, then use tranexamic acid/NSAIDs Progestogen throughout cycle, NOT just luteal
- #25 Direct – can see what ur doing, can see polyps etc Non hyst – doesn’t require theatre/anaesthesia
- #34 Complication – perforation 1.3% cervical lacerations 2.2%
- #35 (a large uterus and/or uterine fibroids make it more difficult to use the less invasive techniques Vaginal route – shorter recovery, fewer complications
- #36 Total is bigger operation Subtotal has slightly higher chance of ongoing menstrual bleeding
- #37 Hysterectomy also anaesthetic, DVTs etc
- #38 Other options have failed Wish for amenorrhea Woman who has been fully informed requests it Nwoman no longer wishes to retain her uterus and fertility