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Learning outcomes

By the end of this tutorial, you will be able to:

demonstrate knowledge of AUB terminology and the FIGO classification system (PALM-COEIN) for causes of AUB and understand the risks and benefits of treatment options

identify ‘red flag’ features requiring secondary care referral

describe the principles of uterine and endometrial assessment using pelvic ultrasound, endometrial biopsy and hysteroscopy and identify the indications for using other imaging modalities in selected groups

interpret the hierarchical three-step treatment approach for HMB

recognize the risks and benefits of: operative hysteroscopic procedures, endometrial ablation, uterine artery embolization and MRI-guided focused ultrasound ablation

counsel women on treatment options explaining the nature, risks and benefits of medical and surgical treatments

recognize the need for appropriate referral for more complex cases for detailed evaluation

use appropriate referral pathways and local protocols if AUB or abnormal findings are identified.

Menstruation

if AUB or abnormal findings are identified. Menstruation Menstruation is a woman's monthly bleeding from her

Menstruation is a woman's monthly bleeding from her reproductive tract induced by hormonal changes of the menstrual cycle. The length of a menstrual cycle is the time from the start of a period to the start of the next.

Beliefs derived from personal experience and cultural, social and educational influences determine whether she perceives the menstrual blood loss to be 'normal' for her.

However, a 'normal' quantity of monthly blood loss (MBL) can be defined objectively for the whole population.

Due to difficulties in determining when a menstrual period begins (e.g. spotting, brown/pink discharge, continuous prolonged bleed), it is often difficult to differentiate between a menstrual period and an intermenstrual bleed (IMB). In the main, the aetiopathology and treatment of IMB differs from heavy menstrual bleeding (HMB).

Normal menstrual cycle

The menstrual cycle (as well as AUB) should be described according to four specific symptomatic components (cycle frequency, duration, volume, regularity of cycle).

Frequency of menses (or length of menstrual cycle)

Mean is 28 days (95% CI 24–38 days); frequent <24 days, infrequent >38 days.

As age increases, the menstrual cycle tends to shorten; age 13–19 years, mean cycle length 35 days (90th centile range: 28–44 days), age 35–52 years, mean cycle length 28 days (90 th centile range: 25–32 days).

As age increases, the frequency of irregular periods reduces. The frequency of irregular periods is around 21% between the ages 15 and 19 years and reduces 11% between ages 40 and 44 years.

Duration of menstruation

Normal 4.5–8.0 days; prolonged >8 days, shortened <4.5 days.

Mean is 5 days (95% CI 4.5–8 days).

As age increases, the duration of menstruation decreases. One study has reported that the mean duration of menstruation changed from 3.9 days at aged 20, to 2.8 days at 40 years. Another study showed the average duration of menstruation was 4.7 days in women aged between 13 to 17 years old and 4.1 days in women aged over 40 years.

Volume of monthly menstrual blood loss (ml)

Mean 40 ml (95% CI 5–80 ml); heavy is >80 ml; light is <5 ml.

In women with no pre-existing menstrual problems, the normal amount of monthly menstrual blood loss (MBL) is 25–50 ml. An early study showed that haemoglobin and

ferritin levels adversely changed at MBL levels beyond 80 ml and suggested this should be considered the upper limit of the population average MBL.

A subsequent study showed that anaemia and iron depletion occurred at two points, first around 60 ml MBL and then around 120 ml MBL. The study concluded that a definition around 120 ml may be more useful for the management of women with HMB as this correlated to when anaemia was most likely to occur.

Regularity of menstrual cycle (cycle to cycle variation over 12 months, measured in days)

Regular cycle-to-cycle variation is between 2–20 days, irregular variation is >20 days or absent.

Components used to describe type of AUB

Normal limits (5th–95th centile)

Frequency of menses (days)

Frequent

<24

Normal

24–38

Infrequent

>38

Duration of flow (days)

Prolonged

>8.0

Normal

4.5–8.0

Shortened

<4.5

Volume of monthly blood loss (ml)

Heavy

>80

Normal

5–80

Median

40

Light

<5

Regularity of menses (cycle to cycle variation over 12 months; in days)

Regular variation: ± 2 to 20 days

Irregular variation: >20 days or absent

Key points

Menstruation is controlled by the cyclical hormonal change in the menstrual cycle.

Normal frequency is between 24–38 days.

Normal duration is 4.5–8 days.

Normal volume is between 5–80 ml.

Regular cycle-to-cycle variation is between 2–20 days.

Definition of HMB

Heavy menstrual bleeding (HMB) is clinically defined as menstrual blood loss (MBL) that is subjectively considered to be excessive by the woman and interferes with her physical, emotional, social and material quality of life.

Quantifying monthly menstrual blood loss (MBL) does not improve clinical care and is not undertaken in modern clinical practice. MBL may be estimated directly (e.g. by collecting all sanitary protection and eluting and quantifying blood by laboratory techniques such as the alkaline haematin test) or indirectly (e.g. Pictorial Blood Loss Assessment Chart [PBAC]; subjective measures).

Objective assessment: a PBAC score greater than or equal to 100 equates to a sensitivity of 86%–91% and a specificity of 82–89% in predicting MBL greater than 80 ml by alkaline haematin test (gold standard reference technique).

Subjective assessment: subjective assessment of MBL combines information of sanitary protection usage, flooding, clots, duration of menstruation and the woman's personal opinion of her menstrual loss. Although this tends to be inaccurate, it is easy to undertake in clinical practice and is the preferred method of assessing HMB.

Prevalence of HMB

HMB has a major adverse effect on the quality of life of many women. Overall, 3% of premenopausal women experience HMB. However, this absolute risk is almost doubled in woman aged 40–51. HMB accounts for around 15% of all secondary care gynaecological referrals in the UK.

It is estimated that HMB costs the UK NHS around £100 million a year.

that HMB costs the UK NHS around £100 million a year. Greater awareness of HMB led

Greater awareness of HMB led by better health education and expanding internet resources has empowered women to seek earlier medical advice and the expectation of greater treatment choice.

Annual rate of women with HMB presenting to service

guidance in England. London: NICE; 2007 Causes of HMB Between 40–60% of women with HMB have

Between 40–60% of women with HMB have no uterine, endocrine, haematological or infective pathology on investigation. These women were formerly termed to have dysfunctional uterine bleeding (DUB) of ovulatory (regular cycle) or anovulatory (irregular cycle) type.

Most HMB is due to a combination of coagulopathy, ovulatory or endometrial dysfunction that does not require secondary referral and treatment can be commenced in primary care. The term DUB should be discarded and PALM-COEIN classification adopted.

Pathological causes of HMB include uterine fibroids (20–30%), uterine polyps (5–10%), adenomyosis (5%); endometriosis rarely presents as AUB, but is identified in <5% of cases of AUB.

Gynaecological malignancy rarely presents as HMB, but can present as prolonged intermenstrual bleeding (IMB), postcoital bleeding (PCB), postmenopausal bleeding (PMB) and as a pelvic mass.

Key points

Heavy menstrual bleeding is a subjective diagnosis as it is defined by the woman based on how it interferes with her quality of life.

HMB affects 3% of premenopausal women.

Pathological causes of HMB include uterine fibroids (20–30%), uterine polyps (5– 10%), Adenomyosis (5%); endometriosis rarely presents as AUB, but is identified in <5% of cases of AUB.

DUB should not be used to describe HMB.

Terminology Used to Describe AUB

Terms to be kept in new terminology

Abnormal uterine bleeding

Any menstrual bleeding from the uterus that is either abnormal in volume (excessive duration or heavy), regularity, timing (delayed

(AUB)

or frequent) or is non-menstrual (IMB, PCB or PMB)

Heavy

For clinical purposes, HMB is defined as excessive menstrual blood loss leading to interference with the physical, emotional, social and material quality of life of a woman, and which can occur alone or in combination with other symptoms. Adverse outcome is greater in women with total MBL that exceeds 80 ml or menses duration >7 days

menstrual

bleeding (HMB)

Intermenstrual

Uterine bleeding that occurs between clearly defined cyclic and predictable menses. Such bleeding may occur at random times or may manifest in a predictable fashion at the same day in each cycle

bleeding (IMB)

Postmenopausal

Genital tract bleeding that recurs in a menopausal woman at least one year after cessation of cycles

bleeding (PMB)

Postcoital

Non-menstrual genital tract bleeding immediately (or shortly after) intercourse

bleeding (PCB)

Chronic AUB

AUB has been present for the majority of the past 6 months. In most cases, chronic AUB is unlikely to require urgent immediate clinical intervention

Acute AUB

Excessive AUB bleeding that requires immediate intervention to prevent further blood loss. Acute AUB may present in the context of existing chronic AUB or might occur without such a history

Terms that should be discarded in new terminology

Menorrhagia

Heavy menstrual bleeding that occurs at expected intervals of the menstrual cycle (cycle length varying from 21 to 35 days)

Oligomenorrhoe

Bleeding that occurs at intervals of >35 days and <6 months,

a

usually caused by a prolonged follicular phase

Polymenorrhoea

Regular bleeding at intervals of less than 3 weeks, which may be caused by a luteal phase defect

Amenorrhoea

No uterine bleeding for at least 6 months

Menometrorrha

HMB at the usual time of menstrual periods and at other irregular

gia

intervals

Metrorrhagia

Uterine bleeding at irregular intervals, particularly between the expected menstrual periods

Dysfunctional uterine bleeding (DUB)

This may be ovulatory or anovulatory HMB. This is diagnosed after the exclusion of pregnancy, medications, iatrogenic causes, genital tract pathology and systemic conditions

The terms listed in the table above, until now, have been widely accepted as appropriate terms to describe AUB. However, there has been concern that such terminology is poorly understood by both doctors and patients and is liable to misinterpretation.

An expert consensus panel on menstrual disorders (Fraser et al 2007) has suggested that:

terms such as menorrhagia, menometrorrhagia, metrorrhagia and dysfunctional uterine bleeding be discarded

AUB should be described according to four specific symptomatic components (cycle frequency, duration, volume and regularity of cycle). For example, instead of stating this woman has menorrhagia, one would state she has normal frequency, prolonged duration, heavy menstrual bleeding (HMB) without any variation between cycles. The terminology suggested by Fraser et al advises using simple universally accepted terminology to describe the four cycle- components:

o

regularity should be specified as irregular, regular or absent

o

frequency should be specified as frequent, normal or infrequent

o

duration should be specified as prolonged, normal or shortened

o

volume should be specified as heavy, normal or light. In describing a cycle as above one would accept the ‘normal’ parameters as outlined by Fraser et al (see normal menstrual cycle section).

No specific guidance has been issued for the terms oligomenorrhoea, polymenorrhoea and amenorrhoea. However, these are better described using cycle frequency and regularity of cycle components.

FIGO classification of the causes of AUB

Continuing on the theme of updating AUB terminology, an expert committee recommended a classification system to describe the causes of AUB in non- gravid women of reproductive age (Munro et al, 2011). They believed a comprehensive classification system would facilitate communication between clinicians, investigators and patients, with the potential to improve patient health outcomes.

The stimulus for this work was concern that women with AUB were often affected by more than one component from the ‘PALM-COEIN’ classification. However, it was not always possible to distinguish whether an individual component was causal or associated with HMB.

FIGO have approved this new classification system and have called it PALM- COEIN:

structural causes for AUB: polyp; adenomyosis; leiomyoma; malignancy and hyperplasia

non-structural causes for AUB: coagulopathy; ovulatory dysfunction; endometrial; iatrogenic; and not yet classified.

Using the full notation ‘PALM-COEIN’ it is possible to define women with AUB who have one or more contributing pathologies. In all cases, the presence or absence of each criterion is noted using 0 if absent, 1 if present, and ? if not yet assessed.

using 0 if absent, 1 if present, and ? if not yet assessed. Reprinted from: Munro

In general, the components of the PALM group are discrete (structural) entities that can be measured visually with imaging techniques and/or histopathology, whereas the COEIN group is related to entities that are not defined by imaging or histopathology (non-structural).

The term 'dysfunctional uterine bleeding’ which was previously used as a diagnosis for AUB that occurs in the absence of systemic or locally definable genital tract pathology, should be discarded and is not included in PALM-COEIN. Women who fit this description generally have any combination of coagulopathy, ovulation or primary endometrial disorder.

The following illustrated table shows how diagnosed pathology can be described used PALM-COEIN terminology.

Type 8 fibroids are leiomyomas that do not relate to the myometrium and include cervical or broad ligament fibroids without direct attachment to the uterus, as well as other so-called 'parasitic' (extra-pelvic) lesions.

FIGO classification of the causes of AUB: examples

Assuming pregnancy is excluded, the following are the main causes for AUB in women of reproductive age group.

Structural

P

Endometrial polyps, cervical polyps

A

Adenomyosis

L

Leiomyoma

M

Premalignancy (endometrial hyperplasia) Malignancy of the genital tract (cervical, endometrial, ovarian, vaginal, vulval, sarcoma of endometrium or myometrium)

Non-structural

C

Systemic coagulopathy, e.g. thrombocytopenia, von Willebrand's disease, leukaemia, warfarin

O

Disorders of ovulatory function, e.g. polycystic ovary syndrome, congenital adrenal hyperplasia, hypothyroidism, Cushing's disease, hyperprolactinaemia

E

Primary endometrial disorders, e.g. disturbances of local endometrial hemostasis, vasculogenesis or inflammatory response (chronic endometritis)

I

Iatrogenic causes, e.g. exogenous sex steroid administration (combined oral contraceptives, progestins, tamoxifen), intrauterine contraceptive device, traumatic uterine perforation

N

Generally rare causes, e.g. arteriovenous malformations, myometrial hypertrophy, sex steroid secreting ovarian neoplasm, chronic renal or hepatic disease, endometriosis

The term ‘dysfunctional uterine bleeding’ which was previously used as a diagnosis for AUB that occurs in the absence of systemic or locally definable genital tract pathology, should be discarded and is not included in PALM-COEIN. Women who fit this description generally have any combination of coagulopathy, ovulation or primary endometrial disorder.

If there is AUB before menarche then a pelvic examination (usually under anaesthesia) should be performed. In cases such as these, the differential

diagnoses would be: malignancy, trauma, sexual abuse, assault or congenital malformations.

Key points

Causes of AUB should be classified as per the PALM-COEIN model.

PALM causes (Polyps, Adenomyosis, Leiomyomas [subserosal and other], Malignancy and hyperplasia) are structural.

COEIN causes (Coagulopathy, Ovulatory dysfunction, Endometrial, Iatogenic, Not otherwise specified) are non-structural.

Assessment of AUB - generic principles

Establish if chronic AUB (>6 months) or acute AUB (urgent intervention required).

Initial step should be to exclude pregnancy.

Understand the differential diagnosis of AUB (i.e. PALM-COEIN classification) and accept the concept that women could be affected by more than one component, but not all components may be causal to AUB.

Undertake relevant gynaecological history and examination.

Screen for coagulopathy (such as von Willebrand disease) by using a specific structured history. If clinical history screen is positive, then undertake coagulation profile and vWD test.

Recommendation for full blood count (FBC), cervical smear, pelvic infection swabs and pelvic ultrasound (and coagulation screen if clinical question screen positive).

Referral to secondary care (one-stop or rapid access clinic) if malignancy is suspected, endometrial biopsy is required, pathology suspected/identified or medical treatment deemed unsuccessful; collectively termed ‘red flag’ features.

Most HMB is due to a combination of coagulopathy, ovulatory or endometrial dysfunction that does not require secondary referral and treatment can be commenced (and successfully undertaken) in primary care.

Uterine/endometrial assessment: investigation using hysteroscopy with endometrial biopsy or ultrasound and endometrial biopsy improves the detection rate of endometrial pathology (malignant and benign) compared with hysteroscopy or ultrasound alone.

Adopt hierarchical three-step treatment approach.

What was novel within the 2007 NICE HMB guideline (CG44) was the recommendation that primary care request a transvaginal pelvic ultrasound scan as a first-line diagnostic tool for identifying uterine and ovarian pathology, rather than defer this investigation until a secondary care referral was made. Transvaginal pelvic ultrasound investigation is indicated if ‘red flag’ features (see diagram below) suggestive of gynaecological pathology are present.

Furthermore, their identification warrants referral of the woman to the local hospital one-stop menstrual disorder clinic or rapid access gynaecology clinic.

Outpatient hysteroscopy, endometrial Pipelle biopsy, or colposcopy can be performed in such clinics to elucidate the precise nature of any uterine or cervical pathology. Saline infusion sonohysterography and 3D transvaginal pelvic ultrasound may increase the diagnostic accuracy of detecting gynaecological pathology, and are an alternative to pelvic ultrasound and hysteroscopy/endometrial biopsy in selected cases.

Overall summary care pathway PCB: postcoital bleeding; PMB: postmenopausal bleeding; IMB: intermenstrual bleeding; 2ww :

Overall summary care pathway PCB: postcoital bleeding; PMB: postmenopausal bleeding; IMB: intermenstrual bleeding; 2ww : urgent appointment within 2-week wait rule for suspected cancer; uterus>10w:

clinical measurements suggests uterus greater 10 weeks size (or uterine cavity >10 cm length); FBC: full blood count (anaemia tends to indicate severe HMB). Red flag features: six features are numbered in the figure that, if present, warrant referral to secondary care. Adapted from: National Institute for Health and Clinical Excellence. Heavy menstrual bleeding. NICE clinical guideline 44. London: NICE; 2007.

Although several assessment and treatment pathways for AUB have been published, they essentially portray the same message. Initial assessment in primary care should include:

1. history: specifically enquiring about menstrual history, pelvic pain, fertility, symptoms of anaemia and impact on quality of life, risk factors for inherited coagulopathy (e.g. von Willebrand disease)

2. abdominal and pelvic examination: specifically, a bimanual examination of the uterus and speculum examination of the cervix, with cervical cytology sampling undertaken if appropriate

3. genital tract infection screening if risk factors are present or cervicitis/endometritis is suspected on history or examination.

4. FBC to check for anaemia

5. pelvic ultrasound if ‘red flag’ features (see diagram above) are present. National Institute for Health and Clinical Excellence. Heavy menstrual bleeding. NICE

NICE HMB care pathway

NICE HMB care pathway
History and clinical coagulation screen
History and clinical coagulation screen

1. Define the nature of bleeding:

age

menstrual or non-menstrual (intermenstrual bleeding, postcoital bleeding, postmenopausal bleeding)

subjective assessment of MBL (sanitary protection usage, flooding, clots, duration of menstruation) and the woman's personal opinion

alteration in the menstrual cycle

pelvic pain and pressure effects

previous medical or surgical treatment for AUB

up-to-date smear test

family history of gynaecological pathology.

2. Identify symptoms that may indicate pathology or need for secondary care referral (summarized as red flag features). Pathology may include:

fibroids (pelvic pain, pelvic mass, pressure/obstructive GI/GUT symptoms)

endometriosis/adenomyosis (cyclical and non-cyclical chronic pelvic pain, dyspareunia, dysmenorrhoea, infertility)

inherited or acquire haemostatic/coagulopathy disorder e.g. von Willebrand disease. See table below. The presence of all three domains on clinical questioning is highly predictive for a haemostatic condition that could be contributory/causal to AUB and indicates the need to perform specific haematological screening blood tests.

Secondary care referral is indicated if pathology is suspected/identified, malignancy is suspected and/or failure of medical treatment. Malignancy may be indicated by: PMB, IMB, PCB, alteration in menstrual cycle, pelvic pain, pelvic mass, pressure/obstructive GI/GUT symptoms, weight loss/gain.

3. Identify pathological effects such as:

anemia (request FBC)

pelvic pain

impaired quality of life.

4. Identify treatment expectations such as:

concerns and needs

future fertility and contraception wishes

need for definitive treatment when offered treatment alternatives

Structured history to screen for coagulopathies (AUB-C)

Domain

Characteristic

1

Heavy menstrual bleeding since menarche

2

One of the following:

postpartum haemorrhage surgical-related bleeding bleeding associated with dental work

3

Two or more of the following symptoms:

bruising 1–2 times per month epistaxis 1–2 times per month frequent gum bleeding family history of bleeding symptoms

Examination, basic investigations and diagnosis

According to NICE HMB guidelines (2007), if history taking reveals HMB without the presence of pathology, then there is no need to undertake a physical examination prior to initiating first-step medical treatment.

This will apply to the vast majority of cases. However, some clinicians have raised concerns with this approach and it would be reasonable to undertake a clinical examination particularly if there was:

uncertainty or overdue routine cervical cancer screening or underlying pelvic/STI infective process

structural pathology (i.e. PALM part of PALM-COEIN classification): given severity of symptoms or co-existing pelvic pain and other symptoms such as IMB, PCB and PMB, weight loss/gain

suspected coagulopathy: HMB or AUB since menarche, tendency to bruise easily, and family history of coagulopathy may indicate an inherited or acquired coagulopathy

suspected ovulatory dysfunction: Oligoamenorhoea, obesity, acne, hirsutism, and acanthosis nigricans may be suggestive of polycystic ovary syndrome or diabetes mellitus, or oligoamenorrhoea and galactorrhoea, which could suggest hyperprolactinaemia.

Clinical examination

General examination – pallor (anaemia)

Abdominal palpation

Visualisation and palpation of the cervix

Bimanual (internal) pelvic examination to estimate uterine size and/or adnexal masses

If there is identification of fibroids that are intracavitary, or a uterine length greater than 12 cm with or without suspected uterine fibroids, then referral for specialist investigation should be made.

Investigations

There is no agreed 'gold standard' as to which methods (or combinations of methods) of investigation are better at identifying certain types of pathology than others and, as such, a comprehensive evaluation is required for women with a high risk of benign or malignant genital tract pathology.

In order to make an assessment more assured, the NICE HMB guidelines has defined 'high risk' women as follows.

Women with AUB who have:

declined or failed an adequate trial of medical treatment

aged >45 years

pathology suspected based on history ± physical examination.

Where AUB includes women with:

abnormal menstrual bleeding

o

HMB with regular and irregular cycles

o

HMB and dysmenorrhoea

o

± pelvic pain

o

± pressure effects on GIT/GU tract

non-menstrual bleeding

o

intermenstrual bleeding

o

postcoital bleeding

o

postmenopausal bleeding.

A comprehensive baseline set of investigations that could be undertaken in primary care would therefore include:

full blood count

cervical smear

pelvic ultrasound

pelvic infection screening (genital tract swab testing).

The NICE HMB guidelines considers pelvic ultrasound as a useful screening investigation for any uterine structural anomalies and ovarian pathology. Ultrasound is more accurate at identifying uterine fibroids than hysteroscopy, whereas hysteroscopy is better at identifying polyps and endometrial disease.

Commencing treatment in primary care or referring to secondary care

For women with HMB who are under 45 years of age with no obvious pathology based on any combination of history, physical examination, GP organised investigations (such as cervical smear, FBC, pelvic ultrasound), there are two options for treatment:

1. immediately refer to secondary care for evaluation

2. commence a 3–6 month trial of medical therapy (e.g. COC, Mirena LNG-IUS) and if there is no improvement refer the woman to secondary care for evaluation.

Because there is no robust evidence to suggest which is the most effective (clinical and cost-effective) option, all further treatment should be decided by both the woman and her GP after due consultation.

Red flag features of AUB indicating secondary care referral

Primary care is under increasing pressure to reduce the need for referral to specialist services. HMB lends itself to this goal, as primary care can readily optimise treatment (particularly by first-line use of Mirena LNG-IUS) and achieve treatment success in the majority of women within the community setting.

There are likely to be numerous locally produced, integrated primary and secondary care pathways for HMB that focus on improving patient outcomes; an aspiration set out by recent NHS reforms.

However, a key fundamental goal of primary care is to appreciate when to refer women presenting with AUB for secondary care assessment (either one-stop ambulatory menstrual disorder clinic or rapid access gynaecology clinic). Such 'red flag’ features of AUB that warrant referral to secondary care are listed in the table below.

Pathology suspected before treatment

 

1

Suspected gynaecological cancer

PCB

PMB

IMB

pelvic mass

cervix lesion

2

Requires endometrial biopsy (to rule out endometrial hyperplasia or endometrial malignancy)

Persistent IMB >45 years with treatment failure Irregular bleeding while on hormone- replacement therapy or tamoxifen

Pathology identified before/after treatment

3 Enlarged uterus (clinically measures >10 weeks size or >10 cm uterine cavity length on uterine sounding)

Fibroids, adenomyosis

4 Moderate/severe anaemia on FBC

Usually benign pathology such as fibroids, endometriosis

 

Uterine/ovarian pathology identified on pelvic ultrasound scan

Identification of coagulation/haemostatic disorder on clinical screening and testing

e.g. von Willebrand disease

Pathology suspected after treatment

 

5 Medical treatment has failed

At least 3 months of drug treatment (at least 6 months of Mirena) and failure is based on woman’s own assessment

6 Patient wishes for surgery

Endometrial ablation, hysterectomy

Uterine and endometrial assessment

Assessment of the uterus and endometrium is conducted in women at high risk of benign or malignant genital tract pathology. This essentially comprises of three components:

1. pelvic ultrasound

2. hysteroscopy

3. endometrial biopsy; either hysteroscopically directed or through 'blind' global uterine cavity Pipelle® sampling.

In addition to new AUB terminology and classification of AUB causes (PALM-COEIN), FIGO also recommended an uterine/endometrial assessment care pathway (depicted below).

Reprinted from: Munro MG, Critchley HO, Broder MS, Fraser IS and the FIGO Working Group

Saline hysteroscopy

Hysteroscopy combined with endometrial biopsy improves the sensitivity and specificity for detection of endometrial malignancy and other pathology compared with either diagnostic tests performed alone.

The endometrial biopsy may either be taken under direct hysteroscopic vision (e.g. using the 5 French operating channel of the hysteroscope and inserting a hysteroscopic grasper or biopsy forceps) or in a non-directed 'blind' manner sampling all surfaces of the uterine cavity e.g. Pipelle® sampler.

Hysteroscopy has a sensitivity and specificity for identifying endometrial cancer of 86% and 99%, respectively.

Hysteroscopy has a sensitivity and specificity for identifying endometrial cancer of 86% and 99%, respectively. Endometrial sampling alone has a sensitivity and specificity of 68–81% and 99–100% for identifying endometrial hyperplasia and endometrial cancer.

Saline infusion sonography

and endometrial cancer. Saline infusion sonography 2D transvaginal pelvic ultrasound images of A) normal uterus

2D transvaginal pelvic ultrasound images of A) normal uterus and right ovay and B) a normal uterus.

Saline infusion sonography (SIS) provides improved visualisation of uterine and endometrial pathology. SIS involves an infusion of sterile saline through a soft, plastic catheter placed in the cervix in conjunction with transvaginal ultrasound. The saline infusion distends the uterine cavity.

in the cervix in conjunction with transvaginal ultrasound. The saline infusion distends the uterine cavity. Enlarge

SIS outlines the intrauterine polyp (Figure B), which could not be easily seen with in the routine transvaginal pelvic ultrasound (Figure A).

in the routine transvaginal pelvic ultrasound (Figure A). Supplementary investigations Consideration may be given to

Supplementary investigations

Consideration may be given to other investigations, which may be requested from both primary and secondary care settings. These are summarised in the table below.

Investigations supplementary to baseline set

MRI and endometrial biopsy

Particularly for assessing suitability for UAE or surgical therapy for fibroids Particularly for advanced stage endometriosis or features suggestive of endometriosis recurrence

Sonohysterography (saline infusion sonography)

Routine pelvic ultrasound identifies more uterine fibroids than hysteroscopy but fewer polyps. Ultrasound will also assess for ovarian pathology

Pelvic infection screening

Particularly reproductive age groups or where sequelae of STI (sexually transmitted infection) are suspected

Von Willebrand's disease (vWD)

Around 5–20% of women with menorrhagia have an inherited bleeding disorder, most often vWD Indications to test for vWD include: menorrhagia since menarche, family history of idiopathic menorrhagia, easy bruising and/or personal history of easy bruising or dental bleeding

Hysteroscopy

Assessment history:

 

Score

Total attempts:

0

Average score:

0%

For each complication listed below, choose the frequency of their occurrence when undergoing diagnostic or operative hysteroscopy. Each option can be used once, more than once or not at all.

A: < 1% frequency

B: < 5% frequency

C: 5–10% frequency

Cervical laceration.

Please Select

C: 5–10% frequency Cervical laceration. Please Select Cervical and/or uterine false passage if inserting

Cervical and/or uterine false passage if inserting hysteroscope under direct vision.

Please Select

if inserting hysteroscope under direct vision. Please Select Uterine perforation +/- damage to abdominal viscera

Uterine perforation +/- damage to abdominal viscera (bowel/bladder).

Please Select

damage to abdominal viscera (bowel/bladder). Please Select Primary haemorrhage. Please Select Fluid overload and

Primary haemorrhage.

Please Select

Please Select Primary haemorrhage. Please Select Fluid overload and dilutional hyponatraemia (particularly

Fluid overload and dilutional hyponatraemia (particularly relevant with first- generation endometrial destruction techniques that used Glycine; now we use bipolar resectoscopes that work in saline uterine distension media).

Please Select

that work in saline uterine distension media). Please Select Electrosurgical injury. Please Select Secondary haemorrhage.

Electrosurgical injury.

Please Select

media). Please Select Electrosurgical injury. Please Select Secondary haemorrhage. Please Select Postoperative

Secondary haemorrhage.

Please Select

injury. Please Select Secondary haemorrhage. Please Select Postoperative infection. Please Select Hysterectomy (due to

Postoperative infection.

Please Select

Please Select Postoperative infection. Please Select Hysterectomy (due to bleeding, perforation). Please Select 23

Hysterectomy (due to bleeding, perforation).

Please Select

Please Select Postoperative infection. Please Select Hysterectomy (due to bleeding, perforation). Please Select 23

Vasovagal syncope.

Please Select

Vasovagal syncope. Please Select Vaginal bleeding and discharge. Please Select Pain: pelvic or shoulder. Please Select

Vaginal bleeding and discharge.

Please Select

Please Select Vaginal bleeding and discharge. Please Select Pain: pelvic or shoulder. Please Select Postmenopausal

Pain: pelvic or shoulder.

Please Select

Please Select Pain: pelvic or shoulder. Please Select Postmenopausal bleeding Unscheduled bleeding in

Postmenopausal bleeding

Unscheduled bleeding in postmenopausal women is abnormal and may indicate the presence of endometrial cancer. Nearly all cases of endometrial cancer (96%) are associated with a thickened endometrium (>4 mm in postmenopausal women), which can be measured by transvaginal ultrasonography. If the scan shows a thickened endometrium >4 mm, then histological sampling is essential in the diagnostic evaluation of abnormal bleeding in postmenopausal women. Hysteroscopy combined with endometrial biopsy improves the detection of intrauterine pathology and has a high specificity (highly unlikely not to detect cancer). SIS is a sensitive technique for the detection of intrauterine, intramural and ovarian pathology but does not provide histological data.

Causes of vaginal bleeding in postmenopausal women

Polyps

30%

Submucosal fibroids

20%

Endometrial atrophy

30%

Hyperplasia

8–15%

Endometrial carcinoma

8–10%

Ovarian, tubal, cervical malignancy

2%

PMB, HRT, tamoxifen and endometrial cancer

More than 90% of the cases of endometrial cancer occur in women over 50 and this cancer is associated with 10% of the cases of postmenopausal vaginal bleeding.

To this end, any unscheduled bleeding while on HRT should be referred to secondary care for further investigation. Manufacturers of HRT have advised that erratic bleeding may occur in the intial 3 months of HRT commencement, or when changing preparations. However, unscheduled bleeding persisting beyond this period warrants urgent referral and investigation.

Tamoxifen usage, like HRT, also increases the risk of developing endometrial hyperplasia or cancer, but TVUS can be misleading in these patients.

Tamoxifen can cause subendometrial cyst development, which makes the endometrium appear thickened in transvaginal sonograms. However, the subendometrial cystic tissue can be differentiated from the endometrium itself in SIS.

can be differentiated from the endometrium itself in SIS. Endometrial thickness The thickness of the endometrial

Endometrial thickness

The thickness of the endometrial stripe can be measured accurately by transvaginal sonography and it has been estimated that 96% of postmenopausal women with endometrial cancer will have an endometrial thickness (ET) >4 mm. At this threshold, the false positive rate is 50%.

Women with PMB whose ET is <4 mm still have a 1–2% risk of having endometrial cancer. TVUS can also show if the endometrial lining is very thin. If so, the bleeding may be due to endometrial atrophy.

It has, therefore, been suggested that as a minimum screening test an endometrial biopsy is required if ET is:

>4 mm in postmenopausal women

>16 mm in premenopausal women

and may be selectively performed in postmenopausal women with ET <4 mm if other historical, clinical or sonographic risk factors are present.

However, endometrial biopsy may fail to provide sufficient tissue for histology and is reported to have up to an 11% false negative rate for the detection of endometrial cancer.

Testing for endometrial cancer

Testing for endometrial cancer Endometrial cancer The preferred investigation of endometrial cancer is hysteroscopy and

Endometrial cancer The preferred investigation of endometrial cancer is hysteroscopy and either blind endometrial biopsy (using Pipelle sampler) or hysteroscopic-guided endometrial biopsy. This diagnostic test may be expanded in a 'therapeutic manner' by performing hysteroscopic resection of any identified intrauterine focal lesions (polyps, submucous fibroids), i.e. see-and-treat. This test has a 99% specificity in women with PMB. If this test is negative, then endometrial cancer is highly unlikely as the post-test probability of endometrial cancer is <0.5%.

Predictive values for endometrial cancer in postmenopausal women

 
 

Sensitivity

Specificity

PPV

NPV

Transvaginal ultrasound (TVU)

67%

56%

7%

97%

Endometrial biopsy (EMB) (blind)*

87%

98.5%

82%

99.1%

SIS

89%

46%

16%

97%

Hysteroscopy and biopsy

86%

99.2%

100%

99.5%

PPV = positive predictive values. NPV = negative predictive values.

Case study

A 56-year-old woman presents with two episodes of PMB. She has taken continuous combined HRT for the last 3 years. Her last cervical smear was 2 years ago and was normal. Below is an image of her transvaginal pelvic ultrasound investigation, which shows her endometrial thickness being 14 mm (1.48 cm).

Based on the patient history and investigations, what assessments would you perform next? Write your

Based on the patient history and investigations, what assessments would you perform next?

Write your answer in the reflective notes before proceeding to the next page.

Assessment

The following key assessments follow a investigation of the woman's clinical history:

systemic examination: examine for lymphadenopathy, anaemia, breast examination (screen for primary malignancy in the breast, which could present as secondary metastases in the genital tract)

abdominal examination: any organomegaly, pelvic masses

pelvic examination: inspection of the vulva, vagina and cervix for any obvious neoplasia. Palpate the cervix and assess uterine size and mobility.

Key investigations

Cervical smear (consider even if recently shown to be normal on national surveillance strategy). Atypical glandular cells of endometrial cell origin on a cervical smear indicate urgent referral for hysteroscopic evaluation as uterine cancer, endometrial hyperplasia or cervical adenocarcinoma are present in 30–40% of such cases.

Transvaginal pelvic ultrasound.

Depending on the pelvic ultrasound:

o

hysteroscopy and endometrial biopsy

o

ovarian tumour markers (CA125, CEA, CA-19-9) if ovarian neoplasm is

suspected.

PMB

Assessment history:

 

Score

Total attempts:

0

Average score:

0%

Answer whether the following statements are true or false.

Tamoxifen can cause sub-endometrial cyst development that may be

detectable by SIS

 

True

  True   False
 

False

  True   False

Endometrial cancer is highly improbable if endometrial thickness is <4 mm in a woman presenting with PMB

 

True

  True   False
 

False

  True   False

SIS is more sensitive than TVUS for detecting focal abnormalities of the endometrium

 

True

  True   False
 

False

  True   False

Hysteroscopy is more sensitive than SIS for uterine polyp detection

 

True

  True   False
 

False

  True   False

Endometrial cancer is present in 40–60% of cases of PMB

 

True

  True   False
 

False

  True   False

Intermenstrual bleeding

Intermenstrual bleeding (IMB) encompasses any bleeding which occurs outside of the woman’s menstrual period. It may affect between 13–21% of women. The incidence in perimenopausal women is as high as 24%. IMB can also include postcoital bleeding. It is a symptom which although largely attributed to a benign cause, can result in significant distress to the patient as it is a commonly known and accepted symptom of cervical cancer.

Causes

Causes of IMB can be classified based on their anatomical site. Commencing at the top of the reproductive tract they are:

Ovarian causes: 1–2% of women will spot at ovulation. Estrogen secreting ovarian tumours can also cause IMB in postmenopausal women.

Uterine causes:

o

iatrogenic – irregular bleeding secondary to hormonal contraceptives (COC, POP, IUS [Mirena]) and hormonal implants. The bleeding may be due to the medication itself, its misuse e.g missed pills, or interactions with other medications like enzyme inducers. Other medications include drugs which affect the clotting pathway e.g. SSRI’s and anticoagulants.

o

infective – endometritis

o

structural benign – uterine polyps and fibroids, adenomyosis

o

structural malignant – endometrial cancer.

Cervical causes:

o

iatrogenic – following examination/smear test

o

infective – cervicitis secondary to infection usually chlamydia or

gonorrhoea

o

structural benign – cervical ectropion can occur spontaneously or in response to increased estrogen levels secondary to pregnancy or the combined oral contraceptive pill. Cervical polyps 1.5–10% prevelance, largely benign (malignancy 0.1% and dysplasia 0.5%)

o

structural malignant – cervical cancer; the estimated prevalence of CIN and cervical cancer is 3–18% in women with PCB.

Vaginal causes:

o

infective – chlamydia and gonorrhoea may cause cervicitis as above. Vulvovaginitis secondary to Trichomonas vaginalis or Candida albicans infection may present with IMB in the context of severe vaginal/vulval oedema or excoriations.

o

structural benign – adenosis (metaplastic cervical or endometrial tissue on the vaginal wall)

o

structural malignant – vaginal cancer.

Examination and investigation

As outlined in the AUB bleeding section, thorough clinical history taking and examination is vital to elicit and identify the possible causes of IMB. Undertaking speculum examination should allow identification of any cervical or vaginal abnormalities. A cervical smear should be taken only if the patient is due one based on national recall (3 yearly for women aged 25–49 and 5 yearly from 49–64).

Referral to colposcopy should be made if there is an obvious abnormality of the cervix or if there are symptoms of cervical cancer (persistent postcoital bleeding or persistent vaginal discharge which cannot be explained by other causes such as infection, polyp etc). The StratOG core training tutorial on Pre-invasive disease of the lower genital

tract has further information on colposcopy.

Cervical cytology with high vaginal and endocervical swabs should be obtained for the diagnosis of STI’s. See the StratOG core training tutorial on Sexually transmitted infections (including HIV) for detailed information on the investigation and management of STI’s.

Causes

Investigation

Treatment

Infection

Bacterial/viral

Appropriate

Endometritis

swabs +/-

antibiotics/antivirals/antifungals

Cervicitis

imaging

Vulvovaginitis

Iatrogenic Breakthrough bleeding Secondary to examination/smear test.

As clinically

Alternating dosage/type of hormone administered +/- tranexamic acid

 

indicated

Structural (benign) Uterine/cervical polyps/fibroids Ectropion Vaginal adenosis

Radiological

Treat the cause in accordance with the woman’s wishes and local resources

imaging +/-

hysteroscopy

Structural (premalignant/malignant) Uterine/cervical/vaginal/v ulval cancer CIN/VaiN/VIN Ovarian estrogen secreting tumors

In accordance with local and national protocols

In accordance with local and national protocols

 

Natural 1–2% of women will have midcycle spotting, associated with ovulation

If clinically

Reassurance

indicated

 
 

IMB case study

A 34-year-old woman presents with a 6-month history of intermenstrual bleeding, prolonged menses (6–12 days) and dysmenorrhoea.

She is experiencing unscheduled bleeding while on a combined oral contraceptive

(COC). She has been taking a COC for 6 years. Her last cervical smear (performed 3 months ago) was normal, as was her clinical pelvic examination.

The consultant refers the woman to secondary care and a transvaginal pelvic ultrasound is requested.

care and a transvaginal pelvic ultrasound is requested. The report states:  uterine cavity 7 cm

The report states:

uterine cavity 7 cm

normal ovaries (left 2 cm, right 3 cm with follicle)

thickened endometrium (12 mm) with a prominent endometrial echo (25 mm by 20 mm) indicating a possible polyp.

The following management options are considered:

Option 1: saline infusion sonography. Option 2: outpatient diagnostic hysteroscopy.

Option 1: saline infusion sonography

hysteroscopy. Option 1: saline infusion sonography Sonohysterography revealed an endometrial polyp originating

Sonohysterography revealed an endometrial polyp originating from the posterior wall of the uterine fundus

Color Doppler imaging demonstrates a vascular stalk (arrow) Option 2: outpatient diagnostic hysteroscopy An intrauterine

Color Doppler imaging demonstrates a vascular stalk (arrow)

Option 2: outpatient diagnostic hysteroscopy

stalk (arrow) Option 2: outpatient diagnostic hysteroscopy An intrauterine polyp (3 x 2 cm) located at

An intrauterine polyp (3 x 2 cm) located at the fundus was identified through outpatient diagnostic hysteroscopy.

Based on the patient history and investigations, what treatment option would you suggest?

Write your answer in the reflective notes before proceeding to the next page.

IMB case study answer

Based on the patient history and investigations, what treatment option would you suggest?

Answer: Hysteroscopic resection is a highly effective therapeutic option. The polyp in this case was resected hysteroscopically in the outpatient setting using Versapoint®.

Key points

Uterine polyps, whether endometrial or submucous fibroid polyps, are a common cause of intermenstrual bleeding (IMB). Once diagnosed by hysteroscopy, uterine polyps are easily treated by hysteroscopic techniques with highly successful results in the vast majority of women.

1477756374

frmReflectiveNote

 

Causes of IMB

 

Assessment history:

 

Score

Total attempts:

0

Average score:

0%

Are the following recognised causes of intermenstrual bleeding (IMB)?

Answer whether the following statements are true or false.

Thrombocytopenia

 

True

  True   False
 

False

  True   False

Sex steroid secreting ovarian neoplasm

 

True

  True   False
 

False

  True   False

Endometrial polyp

 

True

  True   False
 

False

  True   False

HRT

 

True

  True   False
 

False

  True   False

Intrauterine device

 

True

  True   False
 

False

  True   False

Etonogestrel implant

 

True

  True   False
 

False

  True   False

Treatment of HMB - a three-step approach

In the early 1990s, it was estimated that at least 60% of women presenting with HMB would have a hysterectomy as the first-line treatment. The majority of these hysterectomies occurred in women without uterine pathology. The number of hysterectomies is now decreasing. This decline can be partially attributed to the implementation of the NICE HMB three-step treatment hierarchy and increased uptake of Mirena LNG-IUS and endometrial ablation treatments. NICE three-step treatment approach The NICE HMB clinical guideline (2007) recommends a three-step hierarchal approach to determining treatment options. The table below utilises this classification and has updated the evidence base for available treatments. The guideline has stated that while Mirena LNG-IUS is preferable to other medical treatments (tranexamic acid, NSAIDs, COC), this recommendation is based on indirect evidence. In a more recent multi-centre randomised controlled trial (ECLIPSE) of 571 women presenting in the primary care setting with HMB, LNG-IUS (Levonorgestrel intrauterine system) was directly compared to usual medical treatments (tranexamic acid, mefenemic acid, combined estrogen and progesterone or progesterone alone therapy). When assessed over a 2-year period, LNG-IUS was more effective than usual medical treatments in improving heavy menstrual bleeding. More women were still using the LNG-IUS at the end of 2 years in view of its beneficial effects. In addition, secondary outcomes such as practical difficulties, family life, work and daily routine, psychological wellbeing were significantly better in women who received treatment with the LNG-IUS. There were no significant between-group differences in rates of surgical intervention or sexual activity scores. An intention to treat analysis is planned in 5 and 10 years. For women with HMB and large fibroids and/or significant symptoms, such as chronic pelvic pain or dysmenorrhoea (pressure symptoms), a hysterectomy or uterine artery embolisation may be offered as first-step therapy. Similarly, women with significant diagnoses like endometriosis can also be offered hysterectomies as primary treatments. Although hysterectomy is a major operation associated with significant morbidity in a minority of cases, it offers a definitive cure and achieves the highest satisfaction rates in the long term.

Treatment

Effect on fibroid size

Effect on HMB

Effect on fertility

First-step treatments (all medical)

 

Tranexamic acid

No effect

Decrease 30–50%

No effect

NSAIDs (e.g. mefenamic acid)

No effect

Decrease 20–40%

No effect

Combined oral contraceptive (synthetic estrogen)

No data

Decrease 40%

Licensed

 

contraceptive

Combined oral contraceptive Qlaira

No data

Decrease 30%

Licensed

 

contraceptive

(natural estrogen)

Oral progestogen (high- dose)

No effect

Decrease 60%

Contraceptive effect or licensed contraception

Intrauterine progestogen (LNG-IUS)

Decrease 30%

Decrease 70–100% (may also treat endometriosis and adenomyosis)

Licensed

contraceptive

GnRH analogues (3–6 months with/without add-back HRT)

Decrease 30%

Decrease 60–100% (causes amenorrhoea in 80– 90% of women)

Likely contraceptive but contraception is advised

Progestogen-only implant (Nexplanon) or Progestogen-only injectable (Depoprovera)

Unknown

Decrease 30–100% (causes amenorrhoea in 15–

20%)

Licensed

contraceptive

Second-step treatment (minimally invasive uterus-conserving surgery)

Hysteroscopic myomectomy (hysteroscopic fibroid resection)

Excision and

Decrease 50–80%

Improved if excising submucous fibroid No effect if excising uterine polyp

removal of

intracavitary

fibroids

Endometrial ablation

No effect

Decrease 80% (may also treat adenomyosis)

Likely contraceptive but contraception is advised following ablation

Transcervical resection of endometrium

Will be able to excise and removal intracavity fibroids

Decrease 80%-100%

Likely contraceptive but contraception is advised following ablation

Laparoscopic

Excise subserosal and non-deeply embedded intramural fibroids

No effect or may decrease up to 30%

No effect or may increase

myomectomy

Second-step OR third-step treatment (established and newly developed minimally invasive uterus-conserving treatments)

Focal fibroid treatment

MRI-guided focused ultrasound therapy

Decrease 15–20%

Decrease 60%

May decrease, have no effect, or improve fertility

Radiofrequency ablation of fibroids (hysteroscopic system is VizAblate

Decrease 50-80%

Decrease 50%

Treatment still

under trial

Global uterus treatment

 

Uterine fibroid

Decrease 30%

Decrease 60–80%

May decrease, have no effect, or

embolisation

 

improve fertility

Laparoscopic uterine artery occlusion (with or without ovarian artery occlusion)

Decrease 20-30%

Decrease 50%-60%

Treatment still

under trial

Doppler-guided transvaginal uterine artery occlusion

Decrease 20-30%

Decrease 40-60%

Treatment still

 

under trial

Third-step treatments (major surgical procedures)

 

Abdominal

Excise subserosal, intramural and intracavitary lesions

Decrease 60–80%

Improved, particularly if uterine cavity is no longer distorted

myomectomy

Hysterectomy

Complete cure

Complete cure

Irreversible

 

contraceptive

 

NICE guidelines for HMB treatment

First-step medical treatment For NICE first-step medical treatments for HMB, see Table 1 'Pharmaceutical treatments proven to reduce menstrual bleeding' on page 7 of the NICE quick reference guide,

CG44 (to change the view of a pdf, you can right-click and select 'Rotate Clockwise', or select the options in the Adobe menu, 'View/Rotate View/Clockwise'). Second- and third-step medical treatment For NICE second- and third-step treatments for HMB, see Table 2, 'Surgical and radiological treatment options for women whose quality of life is severely impacted' on page 8–9 of the NICE quick reference guide, CG44.

Levonorgestrel-releasing intrauterine system (LNG-IUS)

The levonorgestrel intrauterine- releasing system (LNG-IUS) is an intrauterine, long-term progestogen-only method of

The levonorgestrel intrauterine- releasing system (LNG-IUS) is an intrauterine, long-term progestogen-only method of contraception currently licensed for 5 years of use. It has a T-shaped plastic frame with a rate-limiting membrane on the vertical stem, releasing a daily intrauterine dose of 20 microgram/24 hours of levonorgestrel with little systemic absorption. The LNG-IUS inhibits endometrial proliferation, thickens cervical mucus and suppresses ovulation. The licensed and non-licensed uses are indicated in the table below.

Licensed in UK

Unlicensed in UK

Contraception (5-year duration)

Dysmenorrhoea

Uterine protection for women receiving tamoxifen therapy

Menorrhagia-DUB

Endometriosis, adenomyosis

Fibroids

Uterine protection with estrogen replacement therapy in perimenopausal and postmenopausal women

Endometrial hyperplasia

Endometrial cancer, if unfit for primary surgery

The main side effect, often cited as the reason for discontinuation, is erratic spotting. This tends to subside 3–6 months from insertion. After 1 year of usage, there is a 71– 95% reduction in objectively measured MBL and around 50% women have amenorrhoea. Indirect comparison has shown that LNG-IUS generates more quality-adjusted life years (QALY) than other medical treatments (tranexamic acid, NSAIDs, COCP) and at a lower cost. Therefore, LNG-IUS is the recommended first-line treatment for HMB. In relation to second-line treatments LNG-IUS produces similar satisfaction rates as endometrial ablation and hysterectomy. A randomised controlled trial compared Mirena with no treatment in women awaiting hysterectomy for menorrhagia and showed the following:

 

Mirena

No treatment

At 1 year

68% continued with Mirena

32% had

 

hysterectomy

At 5 years

58% continued with Mirena

42% had

 

hysterectomy

Cost–benefit

Mirena was 40% cheaper than hysterectomy

 

analysis:

1477756708

frmReflectiveNote

Endometrial resection and endometrial ablation

There are several minimally invasive procedures to destroy the endometrium in premenopausal women with menorrhagia due to benign causes for whom childbearing is complete.

Traditionally, first-generation techniques involved resection (transcervical resection of the endometrium [TCRE]) or ablation (rollerball) of the endometrium under direct hysteroscopic vision using electrocautery (either monopolar or bipolar).

First-generation techniques required experienced operators and were associated with complications dependent on both operator experience (e.g. uterine perforation) and the method itself (e.g. dilutional hyponatraemia if using glycine uterine distension in monopolar diathermy TCRE).

glycine uterine distension in monopolar diathermy TCRE). A) Transcervical resection of the endometrium, B)

A) Transcervical resection of the endometrium, B) Hysteroscopic rollerball ablation

Second-generation techniques, compared with those of the first, are non-resectoscopic (not performed under hysteroscopic vision), only ablate the endometrium, are easier to learn and perform and have lower rates of serious complications.

Randomised controlled trials comparing first- and second-generation techniques have found no significant differences in terms of amenorrhoea, bleeding patterns, premenstrual symptoms, patient satisfaction or quality of life. However, all second- generation ablation techniques have significantly shorter operating and theatre times than first-generation techniques and incurred fewer perioperative adverse effects.

Short-term effectiveness (up to 2 years) is high for first- and second-generation endometrial destruction: around 25–35% of women treated experience amenorrhoea, with over 90% experiencing satisfactory reduction in menstrual blood loss without the need for further treatment.

Furthermore, 95% of women return to normal activities by 2 weeks. However, upon longer follow up (around 5 years), around 20–30% of women opting for ablation will either be dissatisfied or require secondary treatment (usually hysterectomy).

Second-generation endometrial ablation techniques

Thermal balloon endometrial ablation (Thermachoice®, Cavaterm®)

Impedance bipolar radiofrequency ablation (NovaSure®)

Hydrothermablation (HydroThermAblator®)

Endometrial cryotherapy (Her Option®).

 Endometrial cryotherapy (Her Option®). Thermal balloon endometrial ablation (ThermaChoice).

Thermal balloon endometrial ablation (ThermaChoice). Gynecare ThermaChoice uterine balloon therapy system uses a balloon filled with heated sugar (dextrose) solution © GYNECARE, a division of ETHICON INC., Somerville, N.J.

© GYNECARE, a division of ETHICON INC., Somerville, N.J. NovaSure impedance controlled endometrial ablation system

NovaSure impedance controlled endometrial ablation system delivers electrical current to a triangular metallic mesh electrode to vaporise the endometrium © Novacept, Inc., Palo Alto, California

current to a triangular metallic mesh electrode to vaporise the endometrium © Novacept, Inc., Palo Alto,

A) Hydro ThermAblator uses heated salt water (saline solution) © BEI Medical Systems Inc., Teterboro, N.J., B) Her Option uterine cryoblation therapy system uses a cryosurgical probe to apply extreme cold © CryoGen, Inc., San Diego

All techniques are performed as day-case procedures with some being able to be performed under local anaesthetic (with or without sedation) in an outpatient setting.

There is evidence to suggest that benefits result from thinning the endometrium (with medical therapy such as GnRHa) prior to ablation, or performing the ablation just after menses is complete. However, most techniques have now been shown to be equally effective without such additional precautions.

Uterus-conserving endometrial ablation treatment may be offered if:

HMB is severe enough to adversely impact on a woman's quality of life

the woman has completed her family

her uterine cavity is normal sized (uterine cavity length <10 cm) with benign histology.

Normally, ablation is offered as a second-step treatment after previous medical treatments have failed. However, it could also be offered as a first-step treatment after a full discussion of outcomes and other treatment options.

Endometrial ablation should only be considered in women who do not wish future fertility, who have a normal-sized uterus (10 cm uterine cavity length or less), and have either no fibroids or submucous/intramural fibroids no larger than 3 cm in size.

Women suitable for endometrial ablation

Endometrial ablation (uterus-conserving) and hysterectomy are treatment options offered to women with unsuccessful medical treatment (including Mirena LNG-IUS) for their menorrhagia. Informed consent is required that provides the individualised risks and benefits of the treatment against other potential alternatives.

However, endometrial ablation is best suited to women whose:

uterus is not greater than 10 cm in size (although microwave ablation may be used in uteri up to 14 cm cavity length)

uterus does not contain large fibroids that may be distorting the uterine cavity

intrauterine cavity does not contain any polyps or fibroids greater than 3 cm, otherwise these should be removed prior to ablation

uterus has not undergone any previous endometrial ablation procedure, active infective process and whose myometrium is at least 10 mm if using the microwave ablation technique

family is complete or they have no desire for future fertility as decreased fecundity as well as the risk (mainly theoretical) of harm to mother and fetus during pregnancy follows ablation.

Recommendations prior to endometrial ablation

1. An endometrial biopsy is obtained and histologically analysed to exclude the possibility of endometrial hyperplasia or endometrial cancer.

2. Hysteroscopy is performed immediately prior to the insertion of the ablation device to ensure that:

any sounding or dilation of the cervix has not caused a perforation or false passage, resulting in subsequent introduction of the ablation device into the wrong space

there is no significant intrauterine pathology that would preclude ablation, e.g. uterine cavity distorted by intrauterine fibroids

the operator can accurately determine uterine cavity length (and cervical canal length if using NovaSure®).

Endometrial ablation

Assessment history:

 

Score

Total attempts:

0

Average score:

0%

Regarding endometrial ablation

Answer whether the following statements are true or false.

Second-generation ablation techniques are less costly than hysterectomy but hysterectomy provides greater gain in quality of life over the long term

 

True

  True   False
 

False

  True   False

Hysteroscopy should be undertaken post-dilation of the cervix and prior to insertion of the ablation device in the uterus to confirm uterine integrity

 

True

  True   False
 

False

  True   False

Endometrial thinning pre-ablation is required for most ablative techniques

 

True

  True   False
 

False

  True   False

Endometrial ablation provides effective contraception

 

True

  True   False
 

False

  True   False

Hysteroscopic sterilisation may be conducted at the same time as endometrial ablation

 

True

  True   False
 

False

  True   False

Endometrial ablative techniques should be undertaken under local anaesthetic where appropriate

 

True

  True   False
 

False

  True   False

Hysterectomy

Vaginal hysterectomy

Individual patient assessment is essential when deciding the route of hysterectomy, and the following factors need to be taken into account:

presence of other gynaecological conditions or disease

uterine size

presence and size of uterine fibroids

mobility and descent of uterus

size and shape of vagina

history of previous surgery.

There is insufficient evidence on the safety and role of total laparoscopic hysterectomy (NICE guidance). However, laparoscopic-assisted vaginal hysterectomy may be offered

to the woman provided she has been informed of the alternatives and their risks/benefits.

Abdominal hysterectomy

Preoperative GnRHa treatment for 3–4 months may facilitate surgery by reducing preoperative anaemia, intraoperative blood loss and the need for transfusion. Studies have shown a reduction of fibroid size of by 60%, which may enable a lower transverse incision (lower morbidity) rather than vertical midline laparotomy incision (higher morbidity) when conducting the abdominal hysterectomy.

Indications

Hysterectomy should be only considered where:

other treatment options have failed or are inappropriate

women have completed their families

there is a wish for amenorrhoea

women (who have been fully counselled) request it or other forms of further treatment are contraindicated.

The five main routes of hysterectomy are:

1. Abdominal hysterectomy (AH)

2. Vaginal hysterectomy (VH)

3. Laparoscopic hysterectomy (LH) which includes:

laparoscopic-assisted vaginal hysterectomy (LAVH). LAVH is a vaginal hysterectomy assisted by laparoscopic procedures that do not include uterine artery ligation laparoscopic hysterectomy [LH(a)]. LH(a) are laparoscopic procedures, which

include uterine artery ligation

4.

Total laparoscopic hysterectomy (TLH)

In TLH there is no vaginal component and the vaginal vault is sutured laparoscopically

5.

Subtotal hysterectomy (STH)

STH (conservation of the cervix) compared with total AH

After STH, there is a 2–7% risk of persisting cyclical bleeding, 2% risk of cervical prolapse and a 1% risk of cervical cancer.

There is no difference between STH and AH in terms of quality of life, constipation, prolapse, satisfaction with sex life, pelvic pain, vaginal bleeding or complication rates.

The decision about the appropriate route for hysterectomy depends on:

the size of the uterus

the size of any uterine fibroids (large uterus and/or uterine fibroids make it more difficult to use less invasive techniques)

the location of any uterine fibroids (their size and presence increases the risk of vascular, ureteric or bladder injury)

the mobility of the uterus

the size and shape of the vagina

operator experience

patient preference

history of previous surgery

the evidence based comparison of the methods: first line, vaginal; second line, abdominal; and third line, laparoscopic.

Evidence based comparison of routes of hysterectomy

A systematic review by Johnson et al has assessed the most appropriate surgical route for hysterectomy in women with benign gynaecological conditions.

The review concluded that the route of hysterectomy should be in the following order of clinical preference:

first line – vaginal

second line – abdominal

third line – laparoscopic.

Furthermore, this review established that:

if possible, VH should be performed in preference to AH because of the rapid recovery time and fewer incidences of febrile episodes postoperatively

depending on the uterine descent in the vagina and operator experience, a large multifibroid uterus can still be removed as a VH rather than AH

if VH is not possible, then LH has some advantages over AH (decreased operative blood loss, rapid recovery, fewer febrile episodes and lower wound infection rates) but at the expense of an increased risk of urinary tract (bladder or ureter) injury and possibly operating time.

Complications of hysterectomy

Complication

AH

VH

LAVH, LH, TLH

Death

0.5 per 1000

 

Major perioperative complications

4.5%

4.3%

7.8% (6.1% is intraoperative)

Severe urinary incontinence*

–5% to +20%*

 

Severe nocturia*

–5% to +10%*

 

Blood transfusion

3–4%*

Bowel injury

0.7%

<0.01

0.2%

 

%

Vascular injury

0.8%

0.9%

1.8%

Pelvic haematoma

4–6%

4–6%

4–6%

Vaginal vault infection

2%

2%

4%

Abdominal wound infection

7%

0%

2%

Conversion to laparotomy

NA

3%

4%

Urinary tract injury (bladder or urethral) 0.8%

1.6%

2.3%

Bleeding

1.6%

<0.01

0.4%

 

%

UTI

5%

1.3%

5%

Chest infection

5%

7%

0.6%

Other febrile condition

13%

7%

10%

Venous thromboembolism

<0.01

<0.01

0.6%

%

%

Table adapted from NICE HMB guideline (2007).

*A negative percentage (i.e. -5%) indicates that hysterectomy was associated with a 5% improvement in urinary incontinence and nocturia as well as a 10–20% worsening of these symptoms.

Hysterectomy

Assessment history:

 

Score

Total attempts:

0

Average score:

0%

Answer whether the following statements are true or false.

The number of hysterectomies performed for benign gynaecological disorders decreased by over 50% between 1993–2002

number of hysterectomies performed for benign gynaecological disorders decreased by over 50% between 1993–2002 True 45

True

False

False Approximately 85% of women are willing to accept a 50:50 chance of treatment failure for

Approximately 85% of women are willing to accept a 50:50 chance of treatment failure for HMB in order to avoid hysterectomy

 

True

  True   False
 

False

  True   False

There is no significant difference in urinary tract injury (includes bladder and ureter) between laparoscopic hysterectomy and abdominal hysterectomy

 

True

  True   False
 

False

  True   False

There is no statistically significant differences in urinary tract injury for LH versus VH or for LH(a) versus LAVH

 

True

  True   False
 

False

  True   False

There are fewer abdominal wall infections and other postoperative infective episodes for LH versus AH

 

True

  True   False
 

False

  True   False

In women undergoing VH compared with AH, hospital stay was shorter and there was a quicker return to normal activities

 

True

  True   False
 

False

  True   False

The presence of fibroids at a hysterectomy increases the risk of operative complications

 

True

  True   False
 

False

  True   False

There is no medical advantage to perform medical pre-treatment before hysterectomy and myomectomy with GnRH-a for 3–4 months for women with enlarged uterine fibroids

 

True

  True   False
 

False

  True   False

The route of hysterectomy to be used should be considered in the following order: first line, vaginal; second line, abdominal; and third line, laparoscopic

 

True

  True   False
 

False

  True   False

Over the short- and long-term, there is higher patient satisfaction with hysterectomy than endometrial ablation

 

True

  True   False
 

False

  True   False

Key points

Utilise the NICE 2007 Heavy menstrual bleeding guideline with its three-step approach. Step one is medical treatment with both hormonal and non-hormonal treatment. Step two is minimally invasive uterus conserving surgery e.g. hysteroscopic fibroid resection, endometrial ablation, transcervical resection of endometrium and laparoscopic myomectomy. Additional treatments have been added to step 2 involving newly developed intervention in keeping with the above. It includes MRI guided focused USS therapy, radiofrequency ablation of fibroids, uterine fibroid embolisation and laparoscopic uterine artery occlusion. Step three involves major surgical procedures e.g. abdominal myomectomy and hysterectomy.

1477757342

frmReflectiveNote

 

Treatment of HMB

 

Assessment history:

 

Score

Total attempts:

0

Average score:

0%

Choose the treatment technique associated with the adverse effects listed in the items below. Each option can be used once, more than once or not at all.

A: Tranexamic acid

B: Uterine artery embolisation (UAE)

C: Myomectomy

D: Non-steroidal anti-inflammatory drugs

E: Combined oral contraceptives

F: Hysterectomy

G: GnRHa (gonadotrophin-releasing hormone analogue)

H: Injected long-acting progestogens

I: Oral progestogen: norethisterone (15 mg) daily

J: Endometrial ablation

K: Oophorectomy at time of hysterectomy

L: Mirena (levonorgestrel-releasing intrauterine system)

Licensed for 5-year therapeutic usage. COMMON: irregular bleeding that may last for over 6 months, hormone-related problems such as breast tenderness, acne or headaches (generally minor and transient). LESS COMMON: amenorrhoea. RARE: uterine perforation at the time of device insertion.

Please Select

perforation at the time of device insertion. Please Select Only taken at the time of menses,

Only taken at the time of menses, no hormonal side effects, non- contraceptive. LESS COMMON: indigestion, diarrhoea, headaches.

Please Select

COMMON: indigestion, diarrhoea, headaches. Please Select Only taken at the time of menses, no hormonal side

Only taken at the time of menses, no hormonal side effects, non- contraceptive. COMMON: indigestion; diarrhoea. RARE: worsening of asthma in sensitive individuals, peptic ulcers with possible bleeding and peritonitis.

Please Select

ulcers with possible bleeding and peritonitis. Please Select Taken daily from days 1–21. Numerous contraceptive and

Taken daily from days 1–21. Numerous contraceptive and non-contraceptive beneficial effects (e.g. reduced risk of ovarian cancer and treatment for

estrogen-sensitive disorders, such as endometriosis and fibroids). COMMON:

hormonal side effects, mood changes, headaches, nausea, fluid retention, breast tenderness. VERY RARE: deep vein thrombosis, stroke, heart attacks.

Please Select

deep vein thrombosis, stroke, heart attacks. Please Select Taken daily from days 5–26. COMMON: hormonal side

Taken daily from days 5–26. COMMON: hormonal side effects, weight gain, bloating, breast tenderness, headaches, acne (but all are usually minor and transient) RARE: depression.

Please Select

usually minor and transient) RARE: depression. Please Select Preparations are licensed for 3 months or 3

Preparations are licensed for 3 months or 3 years. COMMON: weight gain, irregular bleeding, amenorrhoea, premenstrual-like syndrome (including bloating, fluid retention, breast tenderness). LESS COMMON: small loss of bone mineral density, largely recovered when treatment discontinued.

Please Select

largely recovered when treatment discontinued. Please Select Preparations are licensed for 4 weeks or 3 months.

Preparations are licensed for 4 weeks or 3 months. COMMON: menopausal- like symptoms (such as hot flushes, increased sweating, vaginal dryness) which may require add-back therapy. LESS COMMON: osteoporosis, particularly trabecular bone with longer than 6 months' use.

Please Select

bone with longer than 6 months' use. Please Select Day-case surgical procedure, able to be performed

Day-case surgical procedure, able to be performed under local anaesthetic in outpatient setting. COMMON: vaginal discharge; increased period pain or cramping (even if no further bleeding); need for additional surgery. LESS COMMON: infection. RARE: uterine perforation (but very rare with second generation techniques).

Please Select

very rare with second generation techniques). Please Select Surgical procedure. LESS COMMON: adhesions (which may lead

Surgical procedure. LESS COMMON: adhesions (which may lead to pain and/or impaired fertility), need for additional surgery, recurrence of uterine fibroids, perforation (if performed by hysteroscopic route), infection. RARE:

haemorrhage.

Please Select

route), infection. RARE: haemorrhage. Please Select In patient surgical procedure. COMMON: infection. LESS

In patient surgical procedure. COMMON: infection. LESS COMMON:

intraoperative haemorrhage, damage to other abdominal organs, such as the

urinary tract or bowel, urinary dysfunction (frequent passing of urine and incontinence). RARE: thrombosis (DVT and clot on the lung). VERY RARE:

death. (Complications are more likely if performed in the presence of fibroids).

Please Select

if performed in the presence of fibroids). Please Select In-patient surgical procedure. COMMON: menopausal-like

In-patient surgical procedure. COMMON: menopausal-like symptoms. Although beneficial outcome is substantial reduction in the risk of developing ovarian cancer.

Please Select

in the risk of developing ovarian cancer. Please Select Day-case procedure. COMMON: persistent vaginal discharge,

Day-case procedure. COMMON: persistent vaginal discharge, post- embolisation syndrome [pain, nausea, vomiting and fever (not involving hospitalisation)]. LESS COMMON: need for additional surgery, premature ovarian failure particularly in women over the age of 45 years, haematoma. RARE: haemorrhage, non-target embolisation causing tissue necrosis, infection causing septicaemia.

Please Select

necrosis, infection causing septicaemia. Please Select AUB investigation and management Assessment history:  

AUB investigation and management

Assessment history:

 

Score

Total attempts:

0

Average score:

0%

The following items are clinical scenarios of women presenting with abnormal uterine bleeding. For each item choose the best diagnostic procedure from the options listed above that enables optimal management. Each option can be used once, more than once or not at all.

A: Suspicious pathology. Physical examination and pelvic ultrasound required. Recommend diagnostic hysteroscopy and endometrial biopsy and laparoscopy.

B: Suspicious pathology. Physical examination and pelvic ultrasound required. Recommend diagnostic hysteroscopy and endometrial biopsy.

C: Suspicious pathology. Physical examination required. Obtain cervical smear. Prompt referral to secondary care for urgent transvaginal pelvic ultrasound.

D: Suspicious pathology. Physical examination required. Obtain cervical smear. Request full blood count.

E: No suspicious pathology. Physical examination not required. Commence first-line treatment.

A 47-year-old woman presents with a 6 month history of intermenstrual

bleeding. Despite this, she still exhibits regular menstrual cycles without associated pelvic pain and without any postcoital bleeding. She currently

uses condoms for contraception, is not clinically anaemic and all previous cervical smears appeared normal. Her last smear was 1 year prior to symptoms.

Please Select

Her last smear was 1 year prior to symptoms. Please Select A 61-year-old woman is concerned

A 61-year-old woman is concerned because over the last week she has been

experiencing vaginal blood loss described as a period-like. Her final menstrual period was when she was around 50 and she has never taken HRT.

Please Select

she was around 50 and she has never taken HRT. Please Select A 41-year-old woman has

A 41-year-old woman has a 2 year history of heavy menstrual bleeding. She

exhibits regular menstrual cycles without any associated pelvic pain and does not suffer from intermenstrual or postcoital bleeding. She is currently using condoms for contraception and is not clinically anaemic. All previous cervical smears normal and her last smear was 1 year prior.

Please Select

normal and her last smear was 1 year prior. Please Select After a 2 month episode

After a 2 month episode of postmenopausal bleeding, a woman presents with a cervical smear reporting 'atypical glandular cells of undetermined significance, possibly endometrial cell origin'.

Please Select

possibly endometrial cell origin'. Please Select Polyps arising from the uterine endometrium Endometrial

Polyps arising from the uterine endometrium

Endometrial polyps are localised hyperplastic overgrowths of endometrial glands and stroma which form projections over the endometrial surface.

Aetiology remains obscure, however it is proposed that, polyps lose their apoptotic cell regulation and overexpress estrogen and progesterone receptors causing them to grow. Endometrial polyps are rare before the age of 20 with the incidence steadily rising after that, peaking in the 5th decade of life and then declining at menopause. Incidence estimates are variable based on the population studied, however, 10% of asymptomatic women (incidental on pelvic ultrasonography) and 24-41% of women with abnormal uterine bleeding (AUB) have endometrial polyps.

Clinical presentation

Asymptomatic

Heavy menstrual bleeding

Postmenopausal bleeding

Prolapse through cervical ostium

Abnormal vaginal discharge

Breakthrough bleeding

Infertility:

o

large or multiple endometrial polyps can contribute to miscarriage and infertility. Evidence also suggests that a polypectomy may improve spontaneous conception rates in women with an endometrial polyp as the only factor contributing to subfertility by normalising endometrial implantation factors

Malignancy

o

polyp size of >1 cm, abnormal uterine bleeding and postmenopausal status are all independent risk factors for malignant polyps. Hysteroscopic markers for malignant endometrial polyps include surface irregularities such as necrosis, vascular irregularities and whitish thickened areas, which are indications for obtaining a histological diagnosis.

Diagnostic modalities

Pelvic ultrasound

Saline infusion sonogram (SIS) – safe, well tolerated, rapid, minimally invasive, highly sensitive and superior to ultrasound in diagnosing polyps

Hysteroscopy – gold standard. Can be used to see and treat at the same sitting.

diagnosing polyps  Hysteroscopy – gold standard. Can be used to see and treat at the
Management Enlarge  Hysteroscopic Polypectomy: o symptomatic polyps o asymptomatic polyps in

Management

Hysteroscopic Polypectomy:

o

symptomatic polyps

o

asymptomatic polyps in postmenopausal women irrespective of size

o

asymptomatic polyps in premenopausal women >1 cm in size.

Observational treatment:

o

asymptomatic polyps in premenopausal women ≤1 cm in size.

Key points

Endometrial polyps are localised hyperplastic overgrowths of endometrial glands and stroma. They can cause HMB, PMB, abnormal vaginal discharge and breakthrough bleeding. When large or multiple they are implicated in subfertility. Polyps of >1 cm, AUB and PBM are all risk factors for malignant polyps. Diagnosis is achieved with USS, SIS and hysteroscopy. They can be observed or removed hysteroscopically (symptomatic, asymptomatic in postmenopausal patient, >1cm in size in an asymptomatic premenopausal patient).

Adenomyosis

Background

Adenomyosis is a benign, common gynaecological condition causing heavy, painful periods in premenopausal women who tend to be multiparous and between 40 and 50 years of age. Overall it is considered to contribute to approximately 10% of all cases of HMB and 30% of all cases of HMB with dysmenorrhoea.

It is defined histologically (usually on a hysterectomy specimen) as the presence of non-neoplastic endometrial glands and stroma in the myometrium. It is often associated with hypertrophy and hyperplasia of the myometrium surrounding the ectopic endometrial tissue. However, the clinical diagnosis of adenomyosis prior to hysterectomy is often inaccurate. This is due to:

variability and non-specific nature of symptoms, which tends to mimic any combination of uterine fibroids, endometriosis and HMB due to ovulatory or endometrial dysregulation

variability of the sensitivity and specificity of pelvic ultrasound to diagnose adenomyosis.

Screening investigations

Transvaginal ultrasound is useful as a screening tool in most patients. Studies on the accuracy of TVS reported variable accuracy indices, with sensitivity and specificity varying between 53%–89% and 50%–99% respectively, provided robust diagnostic criteria are used (e.g. enlarged globular, regular uterus with no fibroids, myometrial cystic areas and a decreased myometrial echogenicity) and an experienced sonographer is undertaking the scan.

However, pelvic ultrasound becomes less predictive for adenomyosis in women with co- existing fibroids. MRI has a higher diagnostic capability, irrespective of the presence or absence of uterine fibroids, with estimates of 85% sensitivity/specificity in diagnosing adenomyosis. The high cost and limited availability, however, hinder its routine use.

Diagnostic hysteroscopy is not considered an accurate method to diagnose adenomyosis. However, it may provide some evidence of potential adenomyosis through identification of the following:

irregular endometrial surface

pitting endometrial defects

altered endometrial vascularisation

cystic endometrial surface hemorrhagic lesions.

The role of invasive hysteroscopic or laparoscopic biopsy remains limited, with only small series reported. The small number and size of biopsies obtained may be insufficient to rule out the disease, especially given that the diagnosis may be influenced by the numbers of uterine sections examined.

Clinical treatment

Management of adenomyosis uteri is hindered by the lack of a reliable, noninvasive diagnostic test. No serum markers are currently available.

There are few randomised controlled trials assessing the effectiveness of treatment in women with adenomyosis given the difficulties in accurate clinical diagnosis. Nonetheless, there are varying levels of evidence to support the following treatments.

Medical:

o

nonhormonal therapy, including mefenamic and tranexamic acid, may be effective for the symptomatic relief of menorrhagia

o

low-dose, continuous combined oral contraceptives with withdrawal bleeds every 4-6 months may be effective in relieving menorrhagia and dysmenorrhea

o

high-dose continuous daily oral progestogens

o

GnRHa agonist

o

Mirena LNG-IUS.

Uterus conserving:

o

balloon endometrial ablation

o

uterus-conserving minimally invasive treatments: uterine artery embolisation, MRgFUS.

Adenomyoma excision at the time of abdominal myomectomy.

Laparoscopic myometrial electrocoagulation induces localised coagulation and necrosis of adenomyosis uteri. This technique may be used in women > 40 years of age who have completed their families, but who wish to avoid hysterectomy. Risks include adhesion formation, bleeding resulting in a hysterectomy and difficulty in precise application resulting in the weakening of the remainder of the myometrial tissue.

Hysterectomy.

New treatments for adenomyosis being trialled include: aromatase inhibitors, selective progesterone receptor modulators (e.g. asoprisnil) and bipolar radiofrequency ablation via hysteroscopy or laparoscopy.

Imaging

Pelvic ultrasound imaging

asoprisnil) and bipolar radiofrequency ablation via hysteroscopy or laparoscopy. Imaging Pelvic ultrasound imaging 55

MRI imaging

MRI imaging Enlarge Key points A benign condition causing heavy painful periods, contributing to 10% of

Key points

A benign condition causing heavy painful periods, contributing to 10% of HMB and 30% of HMB with dysmenorrhoea. Histologically it is defined as the presence of non-neoplastic endometrial glands and stroma in the myometrium. On USS it is represented by an enlarged globular regular uterus with no fibroids, myometrial cystic areas and decreased myometrial echogenicity. MRI diagnostic rates are higher than USS. There are no serum markers available. Management options include:

medical – mefanamic, tranexamic acid, low dose COC, high dose continuous progesterones, GnRHa agonists and the Mirena LNG-IUS uterus conserving – balloon ablation and uterine artery embolisation adenomyoma excision at abdominal myomectomy laparoscopic myometrial electrocoagulation hysterectomy.

Leiomyoma (fibroids)

Uterine fibroids Uterine fibroids are smooth muscle tumours of the uterus. While they are generally

Uterine fibroids

Uterine fibroids are smooth muscle tumours of the uterus. While they are generally benign, occasionally (<1%) malignant transformations can occur (leiomyosarcoma).

Uterine fibroids are generally age-related and are a commonly occurring pathology. They are more common in African-Caribbean women than any other ethnicity. They vary tremendously in size from millimetres to tens of centimetres and are associated with heavy periods, pressure symptoms and occasionally pain.

Fibroids are responsive to the female hormones (estrogen and progesterone), generally shrinking to a degree at menopause. They are classified as subserosal, intramural and submucous according to their uterine location (see image below).

Site, size and number of fibroids are linked to the level of MBL.

Enlarge Presentation, complications and investigations Presentation There is a wide spectrum on how women are

Presentation, complications and investigations

Presentation

There is a wide spectrum on how women are diagnosed with fibroids. Most women are referred due to symptoms. However, a significant number of women are incidentally diagnosed with uterine fibroids and are essentially asymptomatic.

In general, fibroid treatment is initiated in women who are symptomatic of fibroid- related symptoms, rather than women with asymptomatic fibroids. Fibroid symptoms include the following:

gynaecological - AUB, HMB, pelvic pain, dyspareunia, pelvic/abdominal mass

anaemia due to HMB

obstetric - infertility, miscarriage, abdominal pain (red degeneration of fibroids midtrimester), preterm labour, malpresentation, caesarean delivery, postpartum haemorrhage

compression of organ systems - abdominal pressure-like effects on gastrointestinal and urological tract and nerve entrapment like symptoms.

Complications

Hyaline degeneration is relatively common and presents as painful enlarged fibroids due to hyaline/cystic degeneration pathological process.

Red degeneration (necrobiosis) occurs typically during pregnancy due to infarction at mid-pregnancy.

Calcification (‘womb stone’) - usually in postmenopausal women.

Sarcomatous (malignant) change. Generally presents as a 0.2% risk. There is a greater risk in women with multiple or rapidly growing fibroids, at advanced age, and if there is a histology is leiomyosarcoma

Infection (abscess) - relatively rare.

Torsion of pedunculated fibroids.

Investigations

Assessment should follow the generic assessment process outlined earlier.

A large fibroid uterus can often be palpated as a firm pelvic mass. The ideal first-line investigation is pelvic ultrasound (transvaginal and transabdominal), although MRI is useful when planning surgery or as a baseline prior to uterine artery embolisation (UAE).

or as a baseline prior to uterine artery embolisation (UAE). Treatment hierarchy for women symptomatic of

Treatment hierarchy for women symptomatic of uterine fibroids

Treatment needs to be highly individualised for women with symptomatic uterine fibroids. Key determinants include the following factors:

uterine size and fibroid size/location/mapping number. Most first-step and second-step treatments are unlikely to be successful in women with grossly pathological (>20w size, multiple fibroids >5cm in size) multi-fibroid uteri

desire for: fertility, uterus preservation and achieve definitive treatment and awareness of risk of symptom recurrence/re-treatment if opting for uterus-conserving treatment

general medical health, age, BMI, previous surgery, previous fibroid treatments, risk/benefit of treatment

preference for focal fibroid treatment (e.g. myomectomy) or global uterine treatment (e.g. UAE).

The NICE guideline for HMB (2007) has indicated that when surgery is necessary for fibroid-related HMB, then the clinical case notes must demonstrate that there has been due discussion and documentation of all treatment alternatives.

Issues like risk of re-treatment are significant for all uterus-conserving treatments; around 20%–30% of all second-step treatments and abdominal myomectomy require re-treatment in 2 years due to fibroid regrowth.

Treatment hierarchy

Seeking contraception

Wishing to

 

conceive

First step

COCs Oral progestogens Injected progestogens Mirena LNG-IUS Short (<6 month) course of GnRHa

Tranexamic acid NSAIDs

Second step

Hysteroscopic myomectomy

Hysteroscopic

myomectomy

+/- Endometrial resection/ablation +/- Mirena LNG-IUS

Laparoscopic

myomectomy

Second step (minimally invasive uterus-conserving treatments)

Uterine artery embolisation Magnetic resonance-guided focused ultrasonography Laparoscopic uterine artery occlusion with/without utero-ovarian occlusion

Transvaginal Doppler guided uterine artery occlusion Bipolar radiofrequency ablation (intrauterine ultrasound-guided or laparoscopic-guided)

Third step

Hysterectomy +/- bilateral salpingo-oophorectomy

Abdominal

myomectomy

All focal fibroid treatments in RED font, Global uterine treatments in BLACK font

Preoperative GnRHa

There is evidence to support the use of a 3–4 month course of GnRHa prior to myomectomy/hysterectomy as pre-treatment, as it:

reduces fibroid size and uterine volume, thereby facilitating conversion of midline vertical laparotomy skin incision to lower transverse abdominal incision in women with large >24w sized multifibroid uteri

improves preoperative haemoglobin levels

reduces perioperative blood loss and transfusion requirements.

Hysterectomy versus abdominal myomectomy

Hysterectomy is a final step treatment to be considered if medical or uterus-conserving options fail. However, hysterectomy can be considered as a first-step treatment if

symptoms are: severe (HMB, pressure-like effects, pain), there is significant pathology (>20 week sized multifibroid uterus) that is unlikely to respond to other treatments; there is a patient preference for definitive treatment and future fertility is not desired.

Another justification for hysterectomy is the combination of age and a significantly pathological fibroid uterus. Abdominal myomectomy in a woman over 41 years with a >20w sized multifibroid uterus is unlikely to substantially improve fertility (although it would alleviate HMB and pain symptoms to some extent) irrespective of whether IVF is undertaken.

Therefore, careful consideration should be given to hysterectomy as the preferred treatment option in such circumstances as it carries lower surgical risks than abdominal myomectomy and will achieve definitive symptom cure. For women below the age of 41, it would be justifiable to perform an abdominal myomectomy for either fertility improvement (if that was desired) and/or alleviation of fibroid symptoms (HMB, pain), or both, if the woman desired to preserve her uterus and rejected minimally invasive uterus-conserving treatment alternatives.

Myomectomy and fertility

There is considerable debate on whether myomectomy improves fertility, although it is established that fibroid presence (submucous and intramural) are associated with adverse fertility and pregnancy outcomes. Based on the limited robust data available, systematic reviews have concluded:

removal of the intracavity component of the submucous fibroid improves fertility (RR 1.72; 95% CI 1.13-2.58)

subserosal fibroids do not affect fertility outcome