13) Gynaecological problems - Heavy Menstrual Bleeding Flashcards
(47 cards)
Definitions of heavy menstrual bleeding
- Excessive menstrual loss that occurs regularly (24-35d) which interferes with quality of life (woman’s perception)
- > 80mL and/or duration of more than 7d (average loss 30-40mL with 90% of women <80mL)
- Changing pads 1-2 hourly, clots >2.5cm
Incidence of HMB
Affects around 20% of women at some point.
5% of women consult GP due to HMB. 20% of outpatient referrals to gynae.
20% of women <60 years have hysterectomy.
Causes of HMB
50% no cause identified.
Fibroids - 10% of menorrhagia, 40% of severe cases.
PALM COEIN - Polyp, adenomyosis, leiomyoma, malignancy, coagulopathy, ovulatory, endometrial, iatrogenic, not otherwise specified.
NICE guidance on examination/investigations required for HMB.
- If history of menorrhagia without other related symptoms can consider pharmacological treatment without physical examination (unless inserting IUS).
- If other symptoms, needs physical examination.
Investigations:
- FBC
- If suspect intracavitary pathology - hysteroscopy
- If suspect large fibroids - pelvic ultrasound
- If suspect adenomysosis - TVUS
Management options for HMB
Group 1: No identified pathology/fibroids less than 3cm/adenomyosis:
- Mirena IUS
- TXA/Mefanamic acid
- CHC
- Cyclical oral progestogen (oral NET 5mg TDS from days 5-26 of menstrual cycle)
- If unsuccessful, refer to consider other options.
Group 2: Fibroids >3cm, or other treatment unsuccessful:
- Options as above
- Ulipristal acetate
- Uterine artery embolisation
- Myomectomy
- Hysterectomy
- Endometrial ablation
Effect of GnRH analogues on fibroids
36% reduction in size and symptoms after 12 weeks (after discontinuation, menstruation returned 4-8 weeks and size returned 4-6 months)
Incidence of fibroids
20-50% of women > 30 years (peak incidence in 40s).
Lifetime prevalence by age 50 70% of white women, 80% black women.
Risk factors for fibroids
Age Early puberty Obesity Black/asian ethnicity FHx
(Risk reduced by pregnancy and progestogen contraception)
FIGO classification of fibroids
Submucosal:
0 - Pedunculated intracavitary
1 - <50% intramural
2 - >50% intramural
Intramural:
3 - 100% intramural but contacts endometrium
4 - 100% intramural
Subserosal
5 - >50% intramural
6 - <50% intramural
7 - Pedunculated subserosal
8 - Other
How is uterine artery embolisation performed?
- Conscious sedation and analgesia
- Percutaneous femoral arterial access
- Catheter manipulated into uterine artery via anterior division internal iliac artery
- Embolic agent then injected under fluoroscopic control
- Takes around 30-90 minutes
Contraindications to uterine artery embolisation
- Current or recent genital tract infection
- Doubt re: diagnosis
- Asymptomatic fibroids
- Pregnancy
- If a patient would refuse a hysterectomy under any circumstances
Relative contraindications:
- Concern that pedunculated submucosal or large submucosal fibroids may slough into cavity with risk cervical obstruction
- Pedunculated subserosal fibroids may also detach and need laparoscopic retrieval
- If symptoms predominantly bulk, volume reduction may not be adequate
Fertility issues with UAE
- Pregnancy is possible
- Effect of UAE on fertility unknown
- Future pregnancies at increased risk of C-section and PPH
Pre-treatment for UAE
- MRI (alters management 22%)
- Ideally remove IUCD pre-procedure
- Single dose IV Abx prophylaxis
Complications of UAE
Immediate:
- Local - groin haematoma, arterial thrombosis, dissection, pseudo aneurysm (uncommon)
- Reaction to contrast (very rare)
- Spasm leading to incomplete embolisation
- Non-target embolisation (rare)
Early (within 30d):
- Post-embolisation syndrome (frequent)
- UTI (very rare)
- DVT (very rare)
Late (>30d) - this is majority of complications:
- Vaginal discharge (16% at 12 months)
- Fibroid expulsion (10%, 6% requiring additional procedure to remove)
- Infection (2%, endometritis 0.5%)
- Hysterectomy (3%)
- Amenorrhoea (2-7%, >85% over age 45)
- Change in sexual function (26% improved, 10% reduced)
Features of post-embolisation syndrome
- Pain, fever, nausea, malaise, raised inflammatory markers.
- Usually self-limiting over 10-14 days.
- 3-5% require readmission for parenteral analgesia and IVI
Management of suspected infection post UAE
- Usually anaerobic
- Admission for IV Abx and IVI
- MRI to exclude abscess/fibroid impaction
In what percentage of women are uterine artery to ovarian artery anastamoses visible
46%
What are you aiming to destroy in endometrial ablation?
Endometrial glands (located at endomyometrial junction) and up to 5mm of myometrium (to get basal glands)
What are the three first generation endometrial ablation techniques?
- Transcervical resection of endometrium
- Roller ball endometrial ablation
- Endometrial laser ablation
When is TCRE preferred and how is it done?
- Preferred when hysteroscopic myomectomy required in conjunction with ablation
- 3mm electrosurgical loop with operative resectoscope. Glycine if monopolar. Saline if bipolar.
When is roller ball endometrial ablation preferred and how is it done?
- Preferred if >1 CS, previous uterine surgery or congenital malformation or repeat ablations.
- Roller ball electrode through resectoscope
What are the second generation endometrial ablation techniques?
- Thermal balloon ablation
- Bipolar radiofrequency endometrial ablation (Novasure)
- Hydrothermal ablation
When are second generation endometrial ablation techniques suitable?
- Uterus no larger than 10-12 week size and sub mucous fibroids <3cm
How does thermal balloon ablation work?
- Catheter and silicone balloon filled with hot liquid at high pressure
- Combination high temp and high pressure - endovascular coagulation and fibrosis
- Newer devices keep constant pressure despite uterine contraction/relaxation
