Mr James Campbell FRCOG

Background - Menstrual disorders

1 in 20 women aged 30-49 present to their

GP per year
7 million (!) is spent per year on primary
care prescriptions
One of the most common reasons for
specialist referral
Accounting for a third of gynaecological
outpatient workload

Heavy menstrual bleeding (HMB)

Major impact on health-related quality of life

Major problem in public health

22% of otherwise healthy women

significant cost
invasive treatments

12% of all specialist referrals

Main presenting symptom for half of the
hysterectomies performed in the UK
Vessey M et al. The epidemiology of hysterectomy: findings of a large cohort study.
Br J Obstet Gynaecol 1992; 99; 402-407.

Increasing prevalence

More periods per lifetime

Earlier menarche
Increased life expectancy
Ability to regulate fertility
Less time spent breastfeeding

More demanding lifestyles and reduced

tolerance of troublesome periods

Menstruation
Shedding of the superficial layers
of the endometrium
following the withdrawal
of ovarian steroids

Normal menstruation

Menarche
- 13 years
Menopause
- 51 years
Regular cycles 5 / 28
Menstrual loss 40ml (<80ml)
Pelvic discomfort

Menstrual disorders

Heavy menstrual bleeding (HMB)

Intermenstrual / Postcoital bleeding

Dysmenorrhoea = painful periods
Premenstrual tension (PMT)
Post-menopausal bleeding
Oligo- or Amenorrhoea

HMB - Etiology

Endometrial origin

Uterine / pelvic pathology

Increased fibrinolysis and prostaglandins

Fibroids / Polyps
Pelvic infection (Chlamydia)
Endometrial or cervical malignancy

Medical disorders

Coagulopathy / Thyroid disease / Endocrine disorders

Iatrogenic (anti-coagulation / copper IUCDs)

Clinical evaluation
& management
Patient presenting
with
heavy menstrual bleeding

TAKE A HISTORY

Relevant history

Frequency and intensity of bleeding

Menstrual diary
Pelvic pain / Pressure symptoms
Abnormal vaginal discharge
Sexual and contraceptive history
Obstetric history
Smear history
History of coagulation disorder

Examination

Clinical examination

General appearance (? Pallor)

Abdominal examination (?Pelvic mass)
Speculum examination
Assess

vulva, vagina and cervix

Bimanual examination
Elicit

tenderness
Elicit uterine / adnexal enlargement

Investigations

Indicated if age > 40 years

or failed medical treatment

FBC / Coagulation screen

Thyroid function (only if clinically indicated)
Smear / Endocervical swabs / High vaginal swabs
Pelvic ultrasound (USS)
Saline hysterosonography (?Polyps)
Hysteroscopy
Endometrial biopsy (Pipelle / D&C)

Hysteroscopy

Endometrial biopsy

Endometrial Hyperplasia
WHO Classification

Simple hyperplasia
No risk of malignant transformation

Complex hyperplasia
Low risk (~5%)

Simple atypical hyperplasia

Unknown risk

Complex atypical hyperplasia

Significant risk (at least 30%)

Endometrium: simple hyperplasia

Complex non-atypical hyperplasia

Complex atypical hyperplasia

Causes of HMB

Endometrial origin
Dysfunctional uterine bleeding

Anovulatory Cycles
Reasons for heavy menstrual bleeding

Endometrium develops

Corpus luteum fails to develop

under the influence of oestrogen

absence of progesterone

Spiral arteries do not develop properly and are

unable to undergo vasoconstriction at the time
of shedding
Endometrium supplied by thin-walled vessels
Result prolonged heavy bleeding

Persistent Anovulation

Infertility
Endometrial hyperplasia
Increased risk of endometrial carcinoma

Management of HMB

Anti-fibrinolytics

Prostaglandin synthetase inhibitor

Tranexamic acid (Cyclokapron)

Mefenamic acid (Ponstan)

Combined oral contraceptive pill (COC)

Progestogens
GnRH analogues
Endometrial ablation
Hysterectomy

Management - Progestogens

Luteal phase progestogens

(only useful if anovulatory)
Long-acting progestogens
(Depoprovera / Implanon)
Mirena IUS

Mirena IUS

Endometrial ablation

Day-case procedure or out-patient setting

1st generation

2nd generation

Trans-cervical resection
Thermal balloon
Microwave
Impedance controlled

Similar outcome to Mirena IUS

Hysterectomy

Treatment of choice for cancer,

but a choice of treatment for menorrhagia
Lilford RJ (1997) BMJ 314; 160 - 161

Surgical access
Total versus subtotal hysterectomy
Removal versus conservation of ovaries
and use of HRT

Abdominal hysterectomy

Vaginal hysterectomy

Uterine pathology
Evaluation & Management
Polyps and Fibroids

Endometrial polyps

Localised overgrowths of endometrium projecting into

uterine cavity
Common in peri- and postmenopausal women
(10 24% of women undergoing hysterectomy)
Account for 25% of abnormal bleeding in both pre- and
postmenopausal women
Typically benign, but malignant change can rarely occur
Non-neoplastic lesions of endometrium containing
glands, stroma and thick-walled vessels
Glands may be inactive, functional or hyperplastic
Association with tamoxifen use

Endometrial Polyp

Endometrial polyps

Diagnosis

Pelvic USS / Saline hysterosonography

Hysteroscopy

Management

Operative removal with polyp forceps / curette

or hysteroscopic resection

Uterine Fibroids
(Leiomyomata)

Occur in 20 30% of women over 30 years

Usually multiple
Almost invariably benign
Variable sizes, up to 20 cm or more
Sex steroid-dependent regress after the
menopause

Submucosal uterine fibroid

Leiomyoma with central degeneration

Leiomyoma

Uterine fibroids

Symptoms

50% asymptomatic
HMB / Dysmenorrhoea
Pressure effects
Infertility
Pregnancy complications

Diagnosis

Clinically enlarged uterus

Pelvic USS
Hysteroscopy / Laparoscopy

Uterine fibroids - Management

Conservative

Medical

Ensure Dx of fibroids and R/O adnexal mass

Tranexamic acid / NSAIDs
Mirena IUS
GnRH agonists

Surgical

Myomectomy
(hysteroscopic / laparascopic / by laparotomy)
Hysterectomy
Uterine artery embolization

Postmenopausal bleeding
Evaluation

Postmenopausal bleeding (PMB)

ALL WOMEN WITH PMB

MUST BE INVESTIGATED
Purpose of investigation:
Exclude malignancy of endometrium and cervix
Endometrial Ca in up to 4% of women with PMB
Precursors of endometrial Ca
(complex hyperplasia +/- atypia)

PMB Exclude malignancy

History and assessment of risk factors

Clinical Examination (!)

R/O cervical carcinoma

Trans-vaginal USS

Use of HRT / Tamoxifen / BMI / Family Hx

Assessment of endometrial thickness (<3mm)

Endometrial sampling (+/- uterine evaluation)

Treatment for endometrial Ca

Hysterectomy +/- radiotherapy

Endometrial Carcinoma

Type I

Oestrogen dependent
80%
Low grade
Endometrioid histology
Assoc with obesity (40%), nulliparity, late menopause, tamoxifen

Type II

Non-oestrogen dependent
Older postmenopausal women
High grade
Serous, clear cell and mixed histology
Tamoxifen; no association with hyperoestrogenism or hyperplasia
Aggressive behaviour

Endometrioid carcinoma

Endometrioid Carcinoma

Endometrial Carcinoma
Prognostic Factors

Histological type
Histological grade
Depth of myometrial invasion
Lymphovascular space invasion
FIGO stage

Case 1

43 year old, para 2 + 0, company executive

Presenting complaint

History

excessive menstrual blood loss

requirement for contraception
Menarche aged 13 years
Used OC pill until 35 years
Smokes 15 / day

Examination

Normal sized uterus and normal adnexae

Case 2

38 year old, para 0 + 0, primary school teacher

Presenting complaint

History

excessive menstrual blood loss and dysmenorrhoea

Menarche aged 12 years
Used OC pill until 25 years
Currently using tranexamic acid with unsatisfactory effect

Examination

Uterus appears enlarged to 18/40 size

Case 3

59 year old, para 0 + 0, retired

Presenting complaint

vaginal bleeding on two occasions over last 3 months

History

Menopause aged 49 years

Polycystic ovarian syndrome
Infertility
BMI = 38 / Overweight for many years

How would you evaluate this case?

Would you carry out any investigations?

What management options would you

discuss and recommend?