1. Mr James Campbell FRCOG

2. Background - Menstrual disorders
1 in 20 women aged 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

3. Heavy menstrual bleeding (HMB)
Major impact on health-related quality of life
22% of otherwise healthy women
Major problem in public health
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;

4. 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

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

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

15. Menstrual disorders Heavy menstrual bleeding (HMB)
Intermenstrual / Postcoital bleeding
Dysmenorrhoea = ‘painful periods’
Premenstrual tension (PMT)
Post-menopausal bleeding
Oligo- or Amenorrhoea

16. HMB - Etiology Endometrial origin Uterine / pelvic pathology
Increased fibrinolysis and prostaglandins
Uterine / pelvic pathology
Fibroids / Polyps
Pelvic infection (Chlamydia)
Endometrial or cervical malignancy
Medical disorders
Coagulopathy / Thyroid disease / Endocrine disorders
Iatrogenic (anti-coagulation / copper IUCDs)

17. Clinical evaluation & management
Patient presenting
with
heavy menstrual bleeding

18. TAKE A HISTORY

19. 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

20. 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

21. 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)

22. Hysteroscopy

23. Endometrial biopsy

24. 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%)

25. Endometrium: simple hyperplasia

26. Complex non-atypical hyperplasia

27. Complex atypical hyperplasia

28. Causes of HMB

29. Endometrial origin “Dysfunctional uterine bleeding”

30. Anovulatory Cycles Reasons for heavy menstrual bleeding
Endometrium develops
under the influence of oestrogen
Corpus luteum fails to develop
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

32. Persistent Anovulation
Infertility
Endometrial hyperplasia
Increased risk of endometrial carcinoma

33. Management of HMB Anti-fibrinolytics
Tranexamic acid (Cyclokapron®)
Prostaglandin synthetase inhibitor
Mefenamic acid (Ponstan®)
Combined oral contraceptive pill (COC)
Progestogens
GnRH analogues
Endometrial ablation
Hysterectomy

34. Management - Progestogens
Luteal phase progestogens
(only useful if anovulatory)
Long-acting progestogens
(Depoprovera / Implanon)
Mirena IUS

35. Mirena IUS

36. Endometrial ablation Day-case procedure or out-patient setting
1st generation
Trans-cervical resection
2nd generation
Thermal balloon
Microwave
Impedance controlled
Similar outcome to Mirena IUS

37. Hysterectomy “Treatment of choice for cancer,
but a choice of treatment for menorrhagia”
Lilford RJ (1997) BMJ 314;
Surgical access
Total versus subtotal hysterectomy
Removal versus conservation of ovaries and use of HRT

38. Abdominal hysterectomy
Vaginal hysterectomy

39. Evaluation & Management Polyps and Fibroids
Uterine pathology
Evaluation & Management
Polyps and Fibroids

40. 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

41. Endometrial Polyp

42. Endometrial polyps Diagnosis Management
Pelvic USS / Saline hysterosonography
Hysteroscopy
Management
Operative removal with polyp forceps / curette or hysteroscopic resection

43. 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

45. Submucosal uterine fibroid

47. Leiomyoma with central degeneration

48. Leiomyoma

49. Uterine fibroids Symptoms Diagnosis 50% asymptomatic
HMB / Dysmenorrhoea
Pressure effects
Infertility
Pregnancy complications
Diagnosis
Clinically enlarged uterus
Pelvic USS
Hysteroscopy / Laparoscopy

50. Uterine fibroids - Management
Conservative
Ensure Dx of fibroids and R/O adnexal mass
Medical
Tranexamic acid / NSAIDs
Mirena IUS
GnRH agonists
Surgical
Myomectomy
(hysteroscopic / laparascopic / by laparotomy)
Hysterectomy
Uterine artery embolization

51. Postmenopausal bleeding
Evaluation

52. 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)

53. PMB – Exclude malignancy
History and assessment of risk factors
Use of HRT / Tamoxifen / BMI / Family Hx
Clinical Examination (!)
R/O cervical carcinoma
Trans-vaginal USS
Assessment of endometrial thickness (<3mm)
Endometrial sampling (+/- uterine evaluation)
Treatment for endometrial Ca
Hysterectomy +/- radiotherapy

54. 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

57. Endometrioid carcinoma

58. Endometrioid Carcinoma

62. Endometrial Carcinoma Prognostic Factors
Histological type
Histological grade
Depth of myometrial invasion
Lymphovascular space invasion
FIGO stage

63. Case 1 43 year old, para 2 + 0, company executive Presenting complaint
excessive menstrual blood loss
requirement for contraception
History
Menarche aged 13 years
Used OC pill until 35 years
Smokes 15 / day
Examination
Normal sized uterus and normal adnexae

64. Case 2 38 year old, para 0 + 0, primary school teacher
Presenting complaint
excessive menstrual blood loss and dysmenorrhoea
History
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

65. Case 3 59 year old, para 0 + 0, retired Presenting complaint History
vaginal bleeding on two occasions over last 3 months
History
Menopause aged 49 years
Polycystic ovarian syndrome
Infertility
BMI = 38 / Overweight for many years

66. How would you evaluate this case?
Would you carry out any investigations?
What management options would you discuss and recommend?