Heavy Menstrual Bleeding - NICE 44 and Uterine Artery Embolisation

Question 1

When should a physical examination and/or investigations (eg USS) be carried out when assessing a woman with heavy menstrual bleeding?

Answer 1

• If the history suggests HMB with structural or histological abnormality, with symptoms such as intermenstrual or postcoital bleeding, pelvic pain and/or pressure symptoms
• Before all LNG-IUS fittings
• Before investigations for structural/histological abnormalities

Question 2

When should women with fibroids be referred to a specialist?

Answer 2

• If they are palpable abdominally

- Intracavity fibroids +/- intracavity length at US or hysteroscopy >12cm

Question 3

Which blood tests should be carried out when investigating women for heavy menstrual bleeding?

Answer 3

• FBC for all women
• Coag disorders if present since menarche and personal/family Hx of bleeding disorder
• TFTs only when other signs of the disease present

NO: ferritin, female hormone testing

Question 4

When should an endometrial biopsy be taken when investigating heavy menstrual bleeding?

Answer 4

• Persistent intermenstrual bleeding

- Treatment failure/ineffective treatment if >=45

Question 5

When should imaging be performed when investigating heavy menstrual bleeding?

Answer 5

• Uterus palpable abdominally
• PV shows mass of uncertan origin
• Failure of pharmeceutical treatment

Question 6

What are the potential unwanted outcomes with:

LNG-IUS?

Answer 6

Common: Irregular bleeding, several months
Headache, breast tenderness, acne
Less common: Amenorrhoea
Rare: Perforation

Question 7

What are the potential unwanted outcomes with:

Tranexamic acid?

Answer 7

Less common: indigestion, diarrhoea, headache

Question 8

What are the potential unwanted outcomes with:

COCP?

Answer 8

Common: Mood changes, headache, nausea, fluid
retention, breast tenderness
Rare: DVT, CVA, heart attacks

Question 9

What are the potential unwanted outcomes with:

Oral progestogen?

Answer 9

Common: Irregular bleeding, weight gain, bloating,
headache, acne, breast tenderness
Rare: depression

Question 10

What are the potential unwanted outcomes with:

Depo?

Answer 10

Common: Weight gain, irregular bleeding, amenorrhoea,
PMS symptoms
Less common: Small loss BMD regained on cessation

Question 11

What are the potential unwanted outcomes with:

GnRH analogues?

Answer 11

Common: Menopausal symptoms

Less common: Osteoporosis esp trabecular bone >6/12

Question 12

What are the potential unwanted outcomes with:

Endometrial ablation?

Answer 12

Common: PV discharge, increased pain/cramping, need
for additional surgery
Less common: infection
Rare: perforation (v. rare with 2nd gen)

Question 13

What are the potential unwanted outcomes with:

Uterine artery embolisation?

Answer 13

Common: Persistent PV discharge, post embolisation syn
Less common: Need for additional surgery, POI esp in
>45, haematoma
Rare: Haemorrhage, non-target embolisation -> tissue
necrosis, infection causing septicaemia

Question 14

What are the potential unwanted outcomes with:

Myomectomy?

Answer 14

Less common: adhesions, need for additional surgery,
recurrence of fibroids, perforation (if
hysteroscopic), infection
Rare: Haemorrhage

Question 15

What are the potential unwanted outcomes with:

Hysterectomy?

Answer 15

Common: infection
Less common: Haemorrhage, organ damage, urinary 
                         dysfunction
Rare: DVT/PE
Very rare: Death

Question 16

What is first line treatment for HMB where there are no fibroids or <3cm in diameter/no distortion of cavity?

Answer 16

• Pharmeceutical Rx
  1. LNG-IUS if >12/12 Rx anticipated
  2. Tranexamic acid/NSAIDs or COCP
  3. Norethisterone 15mg daily day 5-26 or depo

(if no horomes then TEX/NSAIDS)
Stop 2. if no improvement over 3 cycles

Question 17

What should be offered for HMB where there are fibroids >3cm in diameter and Hb =< 102?

Answer 17

Offer ulipristal acetate 5mg (up to 4 courses)

Consider if Hb >102

Question 18

When should endometrial ablation be considered?

Answer 18

• Normal uterus, fibroids up to 3cm in diameter

- Preferable to hysterectomy if HMB alone and uterus <10/40 sized

Question 19

Which type of ablative technique does not require endometrial thinning?

Answer 19

Fluid-filled thermal balloon endometrial ablation (TBEA)

Question 20

When are first-generation ablation techniques (for example, rollerball endometrial ablation [REA] and transcervical resection of the endometrium [TCRE]) appropriate?

Answer 20

If hysteroscopic myomectomy is to be included in the procedure

Question 21

When should consideration for surgery/UAE be considered first line treatment?

Answer 21

Large fibroids and other symptoms e.g. dysmenorrhoea, pressure

Question 22

When should pretreatment before hysterectomy/myomectomy with GnRH analogue be considered

Answer 22

Fibroids causing enlarged/distorted uterus

For 3-4/12

Question 23

How many women undergoing UAE will need a second intervention in 5 years?

Answer 23

2/3

Question 24

What are contraindications to UAE?

Answer 24

• Current/recent pelvic infection
• Pregnancy
• Not prepared to accept small risk of hysterectomy if there is a complication
• Significant doube re: benign pathology

Question 25

What are the immediate complications of UAE?

Answer 25

• Groin haematoma, arterial thrombosis, dissection, psuedoaneurysm
• Iodine contrast reaction
• Incomplete embolisation due to spasm in uterine artery
• Non target embolisation (esp ovary)

Question 26

What are the early complications of UAE (30/7)?

Answer 26

• Post embolisation syndrome (usually self limits 10-14/7)
  - Readmission 3-5% for IV fluids/analgesia
• Very rare; VTE, UTI

Question 27

What are the late complications of UAE (>30/7, can be up to 4 years)?

Answer 27

• Vaginal discharge - 16% persist >1yr
• Fibroid expulsion - 10%, more likely if submucosal
• Infection - 0.5% endometritis
• Amenorrhoea - increases with age
• Change in sexual function (better in 26%, worse in 10%)