13) Gynaecological problems - Heavy Menstrual Bleeding Flashcards
Definitions of heavy menstrual bleeding
- Excessive menstrual loss that occurs regularly (24-35d) which interferes with quality of life (woman’s perception)
- > 80mL and/or duration of more than 7d (average loss 30-40mL with 90% of women <80mL)
- Changing pads 1-2 hourly, clots >2.5cm
Incidence of HMB
Affects around 20% of women at some point.
5% of women consult GP due to HMB. 20% of outpatient referrals to gynae.
20% of women <60 years have hysterectomy.
Causes of HMB
50% no cause identified.
Fibroids - 10% of menorrhagia, 40% of severe cases.
PALM COEIN - Polyp, adenomyosis, leiomyoma, malignancy, coagulopathy, ovulatory, endometrial, iatrogenic, not otherwise specified.
NICE guidance on examination/investigations required for HMB.
- If history of menorrhagia without other related symptoms can consider pharmacological treatment without physical examination (unless inserting IUS).
- If other symptoms, needs physical examination.
Investigations:
- FBC
- If suspect intracavitary pathology - hysteroscopy
- If suspect large fibroids - pelvic ultrasound
- If suspect adenomysosis - TVUS
Management options for HMB
Group 1: No identified pathology/fibroids less than 3cm/adenomyosis:
- Mirena IUS
- TXA/Mefanamic acid
- CHC
- Cyclical oral progestogen (oral NET 5mg TDS from days 5-26 of menstrual cycle)
- If unsuccessful, refer to consider other options.
Group 2: Fibroids >3cm, or other treatment unsuccessful:
- Options as above
- Ulipristal acetate
- Uterine artery embolisation
- Myomectomy
- Hysterectomy
- Endometrial ablation
Effect of GnRH analogues on fibroids
36% reduction in size and symptoms after 12 weeks (after discontinuation, menstruation returned 4-8 weeks and size returned 4-6 months)
Incidence of fibroids
20-50% of women > 30 years (peak incidence in 40s).
Lifetime prevalence by age 50 70% of white women, 80% black women.
Risk factors for fibroids
Age Early puberty Obesity Black/asian ethnicity FHx
(Risk reduced by pregnancy and progestogen contraception)
FIGO classification of fibroids
Submucosal:
0 - Pedunculated intracavitary
1 - <50% intramural
2 - >50% intramural
Intramural:
3 - 100% intramural but contacts endometrium
4 - 100% intramural
Subserosal
5 - >50% intramural
6 - <50% intramural
7 - Pedunculated subserosal
8 - Other
How is uterine artery embolisation performed?
- Conscious sedation and analgesia
- Percutaneous femoral arterial access
- Catheter manipulated into uterine artery via anterior division internal iliac artery
- Embolic agent then injected under fluoroscopic control
- Takes around 30-90 minutes
Contraindications to uterine artery embolisation
- Current or recent genital tract infection
- Doubt re: diagnosis
- Asymptomatic fibroids
- Pregnancy
- If a patient would refuse a hysterectomy under any circumstances
Relative contraindications:
- Concern that pedunculated submucosal or large submucosal fibroids may slough into cavity with risk cervical obstruction
- Pedunculated subserosal fibroids may also detach and need laparoscopic retrieval
- If symptoms predominantly bulk, volume reduction may not be adequate
Fertility issues with UAE
- Pregnancy is possible
- Effect of UAE on fertility unknown
- Future pregnancies at increased risk of C-section and PPH
Pre-treatment for UAE
- MRI (alters management 22%)
- Ideally remove IUCD pre-procedure
- Single dose IV Abx prophylaxis
Complications of UAE
Immediate:
- Local - groin haematoma, arterial thrombosis, dissection, pseudo aneurysm (uncommon)
- Reaction to contrast (very rare)
- Spasm leading to incomplete embolisation
- Non-target embolisation (rare)
Early (within 30d):
- Post-embolisation syndrome (frequent)
- UTI (very rare)
- DVT (very rare)
Late (>30d) - this is majority of complications:
- Vaginal discharge (16% at 12 months)
- Fibroid expulsion (10%, 6% requiring additional procedure to remove)
- Infection (2%, endometritis 0.5%)
- Hysterectomy (3%)
- Amenorrhoea (2-7%, >85% over age 45)
- Change in sexual function (26% improved, 10% reduced)
Features of post-embolisation syndrome
- Pain, fever, nausea, malaise, raised inflammatory markers.
- Usually self-limiting over 10-14 days.
- 3-5% require readmission for parenteral analgesia and IVI
Management of suspected infection post UAE
- Usually anaerobic
- Admission for IV Abx and IVI
- MRI to exclude abscess/fibroid impaction
In what percentage of women are uterine artery to ovarian artery anastamoses visible
46%
What are you aiming to destroy in endometrial ablation?
Endometrial glands (located at endomyometrial junction) and up to 5mm of myometrium (to get basal glands)
What are the three first generation endometrial ablation techniques?
- Transcervical resection of endometrium
- Roller ball endometrial ablation
- Endometrial laser ablation
When is TCRE preferred and how is it done?
- Preferred when hysteroscopic myomectomy required in conjunction with ablation
- 3mm electrosurgical loop with operative resectoscope. Glycine if monopolar. Saline if bipolar.
When is roller ball endometrial ablation preferred and how is it done?
- Preferred if >1 CS, previous uterine surgery or congenital malformation or repeat ablations.
- Roller ball electrode through resectoscope
What are the second generation endometrial ablation techniques?
- Thermal balloon ablation
- Bipolar radiofrequency endometrial ablation (Novasure)
- Hydrothermal ablation
When are second generation endometrial ablation techniques suitable?
- Uterus no larger than 10-12 week size and sub mucous fibroids <3cm
How does thermal balloon ablation work?
- Catheter and silicone balloon filled with hot liquid at high pressure
- Combination high temp and high pressure - endovascular coagulation and fibrosis
- Newer devices keep constant pressure despite uterine contraction/relaxation
Contraindications to thermal balloon ablation
Classical CS
Transmural myomectomy
How does Novasure ablation work?
- Delivers radio frequency energy to endometrium until tissue impedance reaches 50 ohms.
- Electrode array conforms to contour of cavity
- Cavity integrity test uses small amount CO2 to check leak/perforation
How does hydrothermal ablation work?
- Under direct hysteroscopic vision. Circulating heated saline at 90 degrees in endometrial cavity.
- Need tight seal at cervix to prevent burns
- Need to induce endometrial thinning with GnRH analogues prior to treatment
Pregnancy rate and complications post endometrial ablation
- Pregnancy rate 0.7% (need effective contraception)
- Complications: miscarriage, ectopic, PTB, IUGR, abnormally invasive placenta, uterine rupture, CS, PPH
Success rates endometrial ablation
80% satisfaction
50% amenorrhoea
20% re-operation
(No difference between 1st and 2nd generation in satisfaction)
Complications with endometrial ablation
Peri-operative complications (around 1% risk each):
- Haemorrhage
- Perforation
- Cervical lacerations
- Endometritis
- Haematometra
Other:
- TURP syndrome secondary to glycine overload (stop procedure at 1.5L deficit)
- Post ablation syndrome - new onset/significant worsening of pain during menstruation as a result of obstruction of menstruation following scarring and synechiae formation
- Post ablation tubal sterilisation syndrome (6-8%): when sterilisation combined with ablation, cyclical pain, retrograde menstruation into obstructed tube
Technique options for hysteroscopic myomectomy
- Surgical resectoscope to resect chips from fibroid
- Cold loop technique to enucleate fibroid in total into cavity
- Miniature morcellators down hysteroscope (TruClear/Myosure)
What percentage of women have continuing cyclical bleeding after subtotal hysterectomy?
5%
What percentage of benign hysterectomies are performed open?
60%
Indications for ulipristal acetate
- Intermittent treatment (each treatment course not exceeding 3m and should only be repeated after a break in treatment) of moderate–> severe symptoms of uterine fibroids in women of reproductive age who are not eligible for surgery.
- One course of pre-op treatment
LFT monitoring whilst on ulipristal acetate (esmya)
- Before initiating each course (don’t do it if ALT/AST>2ULN)
- Monthly during first two courses
- 2-4 weeks after end of each course
- Stop essay and monitor closely if ALT/AST>3ULN
Success rates for uterine artery embolisation
80-90% asymptomatic or significantly improved symptoms at one year with 40-70% reduction in fibroid volume.
Approx 1/3 will require re-intervention.
Over what time period is the learning curve for laparoscopic myomectomies
4 years
What is the risk of LMS in specimen presumed to be a fibroid?
<30 years: <1 in 500
40-45: 1 in 400
50-55: 1 in 200
75-80: 1 in 100
Risk factors for LMS
Age African Origin Tamoxifen > 5 years Pelvic radiation Hereditary predisposition
Methods to minimise blood loss during laparoscopic myomectomy
Pre-op:
- GnRH analogues significantly shrink but can disrupt surgical planes
- Ulipristal for shrinkage
Intra-op:
- Pre-op misoprostol (400micrograms PV)
- Vasopressin or bupivicaine/adrenaline into either pericapsuar space or uterovesical fold adjacent to uterine arteries
How to close uterus after laparoscopic myomectomy?
If cavity breached - repair 3-0 monocryl
Myometrial closure (multilayer) can use barbed suture
Serosal closure - continuous 2-0 or 3-0 monofilament
Risk of future uterine rupture after laparoscopic myomectomy?
1%
Rate of conversion to open after lap myomectomy
1%
Risk of emergency hysterectomy after lap myomectomy
0.3%
Overall complication rate (+major complications) for laparoscopic myomectomy
11% (2% major)
Risk of parasitic myomata/disseminated peritoneal leiomyomatosis
0.1-1%
In what percentage of cases is the diagnosis of LMS obscured by unconfined corporeal morcellation?
20%
