Abnormal Uterine Bleeding Emma Readman Gynaecologist, Endosurgeon Endosurgery Unit, MHW. Gynaecologist in Charge, Ambulatory Hysteroscopy, MHW

Abnormal Uterine Bleeding: More Heavier than normal bleeding Prolonged uterine bleeding >10days Frequency < than 3 weeks Intermenstrual spotting or bleeding Post coital bleeding

Increased bleeding: pathogenesis Structural Vs Functional Structural – EXCLUDE PREGNANCY  IUDs  Polyps  Fibroids   bleeding by endometrial surface area  30% to 70% women have fibroids,  bleeding caused by those situated near or adjacent to endometrium, or that otherwise expand endometrial surface area Otherwise often ASYMPTOMATIC,COEXISTANT Endometrial cancer  Endometrial hyperplasia

Menstrual cycle

Functional bleeding Functional: Ovulatory Vs Anovulatory Ovulatory loss of local endometrial haemostasis Progesterone withdrawal mediated spiral artery vasoconstriction, modulated by prostaglandins (PG), decreased ratio therefore vasodilates

Menorrhagia: Pathogenesis PGs also opposed by nitrous oxide Other proteolytic enzymes Anovulatory Bleeding: Systemic in nature: hypothalamo- pituitary-ovarian axis Also local haemostatic mechanisms rendered deficient

Menorrhagia: Pathogenesis Also bleeding disorders:Von Willebrande ’ s Disease 10.7% in women with menorrhagia(US centres disease control and prevention) Enhanced fibrinolysis

Clinical evaluation

Medical Options Fe therapy Antifibrinolytics Cyclo-oxygenase inhibitors Progestins Continuous/cyclic Local Inplantable Oestrogens plus progestins Androgens GNRH agonists and antagonists

Antifibrinolytics Tranexamic acid 1g QID first 4 days cycle for ovulatory DUB Virtually all cases bleeding reduces % Placebo controlled trials show no incr GIT Ses (Cochrane review) No evidence incr risk thromboembolic disease even if high risk (Lindoff ’ 93)

Cyclo-oxygenase inhibitors (NSAIDS) Unclear exactly how work but likely generally reduce PGs locally, therefore vasoconstrict 5/7 trials Cochrane showed mean menstrual blood loss decreased c/w placebo, 2/7 no change. Trials usually used mefanamic acid(Ponstan) mg 2-4x daily, also naproxen and ibuprofen Randomised trials comparing danazol & tranexamic acid to NSAIDS show both superior

Progestins: cyclic 10/7 Most of world literature uses norethisterone >= 50% with anovulatory DUB get regulated cycles with cyclical norethisterone, 10 days per month (luteal phase prog) Women with ovulatory DUB unlikely benefit, may get worse Cochrane says less effective than tranexamic acid, danazol, Mirena in ovulatory DUB if used 10/7 using tranexamic acid better for general health, IMB and social and sexual functioning (c/w luteal phase prog)

Progestins: cyclic (long cycle) and continuous Norethisterone 5mg TDS days 5-26 reduced menstrual vol by 87% Only 22% were willing to continue therapy beyond 3/12, preferred IUD. Continuous progesterone no published data with DUB

Progestins:Local Mirena, 20mcg levonorgestrel daily 5 ys Greatest impact on bleeding volume of any med treatment if ovulatory (94% decr blood vol at 3/12, 76% of women wanted to continue post 3/12) Not clear if anovulatory IUD c/w hysteroscopic endometrial ablation by experts showed 79% decr Vs 89% at 12/12, equivalent satisfaction Scandinavian open trial with ovulatory DUB scheduled for hysterectomy, 64.3% elected to cancel op c/w 14.3% allocated to current med mx

Progestins: Implantable Implanon (etonogestrel,3rd gen prog) 3 ys Less bleeding, variable pattern 30-40% cycles amenorrhoeic (c/w 51% Depo) 30% infrequent bleeding (c/w 16% Depo) 10-20% frequent or prolonged bleeding (c/w 35%) Usually know within 3/12 what pattern will be but stabilises at 12/12

OCPs Generally considered effective in Mx of both ovulatory and anovulatory However, few available data to support 1 RCT demonstrated 50% reduced flow(small sample size) 1 RCT compared triphasic OPC & placebo anovulatory DUB 50% “ much improved ” vs 20%, with better life table scores Nuvaring

GnRH and Danazol Danazol >200mg daily, 50% individuals experience decrease menstrual vol,more effective than Ponstan Ses mean usually not use GNRH plus addback useful ovulatory and anovulatory, not licensed for this use Australia

Surgery Hysteroscopic endometrial ablation Laser not common usage-slow, costly, training issues Electrical loop resection Vs ablation Non-hysteroscopic endometrial ablation

Endometrial Ablation

Factors that effect outcome of HER/ablation Better success women>45 Surgeon experience Adenomyosis worse outcome In experienced hands, success rates larger uteri may be equiv to smaller uteri

Nonhysteroscopic endometrial ablation Radiofrequency electrosurgical: Vestablate Novasure Local hyperthermia: Cavaterm HydroThermAblator Thermachoice Cryotherapy Microwave

Novasure

Randomised trials comparing HER/ablation & hysterectomy 90% success, equal amenorhoea to hypomenorrhoea (multiple studies) If retreat failures, 50% success Cochrane shows greater patient satisfaction with hysterectomy Shorter hospital stays, fewer complications, less cost and earlier return to normal in HEA Reoperation rates in HEA increase steadily with time, only 1 trial 4 year follow up-40% reoperation rates

Alternative therapies garlic Panax ginseng Chaste tree Wild yam Cramp bark Helionas root

Alternative therapies Garlic Inhibits platelet aggregation in a dose dependent fashion Increased fibrinolysis Discontinue use 7 days prior to surgery Advise against use if low platelets Ginseng Many different ginsenosides different effects Steroidal saponins Lower post prandial glucose May irreversibly inhibit platelet aggregation Stop ginseng 1 week prior to surgery

Case One Mrs MM, a 24 year old has always had heavy periods, sexually active Tried OCP, no success 30 and 50 mcg, Wants children in the next few years

Case two Mrs CC is a 43 year old, had 3 children LUSCS Periods becoming increasingly heavy over last four years, now flooding, dysmenorrhoea Needs contraception too

Case three Ms PV is a 45 year old Heavy irregular periods increasing over last 2 years Some hot flushes