1. Heavy Menstrual Bleeding

2.  Also called menorrhagia  Excessive menstrual bleeding which interferes with a woman’s physical, social, emotional or material quality of life

3. Causes of Heavy Menstrual Bleeding  Bleeding disorders – rare  Endometrial Hyperplasia – early teens, 40s, throughout reproductive life in women with polycystic ovarian syndrome  Fibroids  Adenmyosis  Endometrial Polyps  Endometrial Cancer  Dysfunctional uterine bleeding

7. Age-related incidence of Cancer of the Endometrium Age-related incidence of Cancer of the Endometrium

8. History  Duration of problem  Cycle, duration of bleeding, intermenstrual bleeding  Impact on life  Type of protection used, how often changed, flooding, clots  Co-existing symptoms e.g. pain, symptoms of anaemia

9. Examination  General –signs of anaemia, hypothyroidism,obesity, acne, hirsutism  Abdominal examination – is the uterus palpable?  Bimanual vaginal examination where appropriate, size of uterus, tenderness, mobility

10. Investigations 1  Screen for bleeding disorders such as Von Willebrand disease in women who have had heavy menses since menarche or with personal of family history to suggest a problem  Thyroid disease if history or physical exam suggestive  No evidence to support hormonal investigations

11. Investigations 2 -Indications for Endometrial Biopsy  Co-existent intermenstrual bleeding  Heavy bleeding, prolonged bleeding in women over 40, no response to medical treatment  Look for endometrial hyperplasia or malignancy

12. Investigations 3 -Ultrasound  Uterus palpable abdominally  Uterus enlarged on bimanual examination  Medical treatment has failed  Transvaginal U.S. usually more helpful  Fibroids, endometrial polyps, adenomyosis

13. Investigations 4 -Indications for Hysteroscopy  To provide additional information on abnormality already inidicated on TVUS e.g. exact location of a polyp or fibroid.

14. Possible Treatments for Heavy Menstrual Bleeding  Tranexamic Acid, NSAIDs  Combined pill, oral norethisterone day 6- 26, injectable progestagens, levo- norgesterol device,GnRh Analogue  Fibroid embolisation, endometrial ablation  Myomectomy.vaginal hysterectomy, abdominal hysterectomy

15. Hysterectomy for HMB  other treatment options have failed, are contraindicated or are declined by the woman  there is a wish for amenorrhoea  the woman (who has been fully informed) requests it  the woman no longer wishes to retain her uterus and fertility.

16. Discussions prior to Hysterectomy  Complcations  Loss of fertility  Sexual feelings  Bladder function  Woman’s expectations  Need for further surgery  Pros and cons of oophorectomy

17. GnRH Analogue  Prior to surgery  When all other treatments are contraindated  If used for over 6 months, then add-back HRT should be added

18. Endometrial Ablation  Where medical treatments have failed, HMB is affecting quality of life, in a woman who does not wish to conceive in the future  Normal uterus or fibroids < 3mm diameter

19. Endometrial Ablation  Transcervical resection of endometrium  Radio-frequency ablation  Thermal balloon ablation  Microwave endometrial ablation  Free fluid thermal ablation

20. Unwanted Effects of Treatment Treatment Potential unwanted outcomes experienced by some women (Common: 1 in 100 chance; less common: 1 in 1000 chance; rare: 1 in 10,000 chance; very rare: 1 in 100,000 chance) Levonorgestrel-releasing intrauterine system Common: irregular bleeding that may last for over 6 months; hormone-related problems such as breast tenderness, acne or headaches, which, if present, are generally minor and transient Less common: amenorrhoea Rare: uterine perforation at the time of insertion Tranexamic acid Less common: indigestion; diarrhoea; headaches Non-steroidal anti- inflammatory drugs Common: indigestion; diarrhoea Rare: worsening of asthma in sensitive individuals; peptic ulcers with possible bleeding and peritonitis

21. Unwanted Effects of Treatments Combined oral contraceptives Common: mood changes; headaches; nausea; fluid retention; breast tenderness Very rare: deep vein thrombosis; stroke; heart attacks Oral progestogen (norethisterone) Common: weight gain; bloating; breast tenderness; headaches; acne (but all are usually minor and transient) Rare: depression Injected progestogen 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

22. Unwanted Effects of Treatments Gonadotrophin-releasing hormone analogue Common: menopausal-like symptoms (such as hot flushes, increased sweating, vaginal dryness) Less common: osteoporosis, particularly trabecular bone with longer than 6-months’ use Endometrial ablation Common: vaginal discharge; increased period pain or cramping (even if no further bleeding); need for additional surgery Less common: infection Rare: perforation (but very rare with second generation techniques) Uterine artery embolisation 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 45 years old; haematoma Rare: haemorrhage; non-target embolisation causing tissue necrosis; infection causing septicaemia

23. Unwanted Effects of Treatments Myomectomy Less common: adhesions (which may lead to pain and/or impaired fertility); need for additional surgery; recurrence of fibroids; perforation (hysteroscopic route); infection Rare: haemorrhage Hysterectomy 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 when hysterectomy is performed in the presence of fibroids.) Oophorectomy at time of hysterectomy Common: menopausal-like symptoms