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 UK Vessey 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 Uterine / pelvic pathology 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 Hyperplasia WHO Classification Simple hyperplasia No risk of malignant transformation Complex hyperplasia Low risk (~5%) Simple atypical hyperplasia Unknown risk Complex atypical hyperplasia Significant risk (at least 30%)

Endometrium: simple hyperplasia

Complex non-atypical hyperplasia

Complex atypical hyperplasia

Causes of HMB

Endometrial origin “Dysfunctional uterine bleeding”

Anovulatory Cycles Reasons 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

Evaluation & Management Polyps and Fibroids 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 Management 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 Diagnosis 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 Carcinoma Prognostic 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 History 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?