Recent Advances in the Management of AUB
Transcript of Recent Advances in the Management of AUB
Advances in the management of Abnormal Uterine Bleeding
Dr. Sikolia WanyonyiResident II
Dr. Timona OburaSenior Instructor & Program Director
AKUH-EA
..If a woman… bears a male child, she shall be …unclean seven days; as at the time of her menstruation, she shall be unclean. Her time of blood purification shall be thirty-three days…she bears a female child, she shall be unclean two weeks..; her time of blood purification shall be sixty-six days.(Lev. 12:2-5)
‘..And a woman was there who had been subject to bleeding for twelve years, but no one could heal her. She came up behind him and touched the edge of his cloak, and immediately her bleeding stopped..’ Luke 8:43-44
Ayurveda, 5000 B.C. describe the amount of normal blood flow during menses as four ‘Anjalis’. An anjali is the volume of fluid that can be accumulated in the hollow when one joins the two hands.
Epidemiology
12 month accumulative incidence Menorrhagia 25% Metrorrhagia 29% Oligomeonorrhea 15% Intermenstrual bleeding 17% Postcoital bleeding 6%
Shapley et al Br. J Gen Pract: 2004; 54:359
Walraven et al. Menstrual disorders in rural Gambia, Stu Fam Plan 2002; 33(3) 261-8
AUB: commonest indication for hysterectomies (46%)
VALUE study. BJOG 2004; 11, 688-694
Normal menstrual bleeding
Endocrine signals ensure Regular Predictable Consistency
Ovarian and Endometrial cycles
Menstrual flow Characteristics*
Normal Abnormal
Duration 4-6 days Less than 2 or more than 7 days
Volume 30mL More than 80 ml
Interval 24-35 days
*Hallberg et al,1966; Cole et al, 1971;
Estimation of menstrual loss
Presence of clots Use of more than one tampoon/pad Pictorial blood loss assessment
Accurate assessment Collect all pads Determine the Hb changes
Onset and cessation menses
Initiation Classic hypoxia theory
Ischemic necrosis of endometrial vasculature
Enzymatic theory autodigestion of the functional layer of
the endometrium
Progesterone withdrawal
Release of intracellular lysosomal enzymes
Stimulates inflammatory response in endometrium
Stimulates matrix metalloproteinases
Cessation Coagulation mechanisms Local vasoconstriction Release of growth factors Increasing estradiol
Anovulatory bleeding
Increased density of abnormal vessels with fragile structure
Focal rupture release of lysosomal proteolytic enzymes
from surrounding epithelial and stromal cells
migratory leucocytes and macrophages
Abnormalities of menstruation
Oligomenorrhea: Intervals >35 days Polymenorrhea: Intervals < 24 days Menorrhagia: Regular normal intervals,
excessive flow or duration Metrorrhagia: Irregular intervals,
excessive flow or duration
Diagnostic Evaluation
Careful menstrual history Laboratory tests; not always useful Aspiration biopsy Uterine imaging Sonohysterography Hysteroscopy
TREATMENT MODALITIES
Goals of treatment
Treat underlying cause Correct associated problems (anemia) Prevent recurrences
Take into consideration the patients’ contraceptive needs and fertility
Treatment
Induce or restore cyclic predictable menses of normal volume and duration
Treatment
The key to successful clinical management is to recognize or identify which mechanism is operating or responsible
Traditional treatment modalities
Progestin therapy
Powerful anti-estrogens Stimulate 17β- hyrodroxysteroid
dehydrogenase and sulfotransferase activity
Inhibit estrogen’s induction of its own receptors
Suppress estrogen mediated transcription of oncogenes
Progestin therapy
Antimitotic, growth limiting effects of progesterone and progestins on endometrium Prevents and reverses hyperplasia Arrest growth during the secretory phase
of the cycle
Progestin therapy
Cyclical treatment with progesterone Works well in women who are
anovulatory Do not suppress HPO axis or ovulation
Combined Oral contraceptive therapy
Prolonged episodes of heavy anovulatory bleeding
Use low dose monophasic combination pills
Treatment should continue for at least 5-7 days even after bleeding stops
Combined Oral contraceptive therapy
Pretreatment TVS To confirm the diagnostic impression To minimize the risk of unsuccessful
treatment with continued heavy blood loss
Combined Oral contraceptive therapy
DMPA in contraceptive doses can be used in women with difficulty in taking COCPs
NSAIDS
PGE2 and PGF2α increase in endometrium during the menstrual cycle
NSAIDS inhibit PG synthesis and decrease menstrual blood loss
Alter balance of TXA2 and PGI2
Decrease menstrual blood loss by 20-40%
Antifibrinolytics
Tranexamic acid Reversibly blocks lysine binding sites on
plasminogen Prevents fibrin degradation More effective than NSAIDS and
progestins Reduce flow by up to 55%
Estrogen therapy
Best used when a denuded or attenuated endometrium is suspected Low yield of biopsy tissue Chronic progestin treatment Thin endometrial stripe
Dilation and curettage
Denudation of the basal layer Stimulates the normal processes
involved in cessation of normal menstrual bleeding
Can be used in acute presentation
NOVEL TECHNIQUES
The LNG-IUS-Mirena®
Has a reservoir containing 52 mg LNG mixed with polydimethylsiloxane
Used as a contraceptive Licensed for AUB in some countries Releases 20µg of levonogestrel per
day
The LNG-IUD-Mirena®
Rapidly absorbed from uterine cavity Plasma concentrations plateaus at 1
month( 0.4-0.6 nmol/L) Intrauterine concentrations of LNG are
1000 times higher in IUS compared to subdermal implants
The LNG-IUD-Mirena
Mode of action
LNG is highly progestational Suppression and atrophy of the
endometrium Stroma swell, decidua, mucosa and
epithelium become inactive Decrease in mean vascular density
Endometrial ablation
Twenty (20) years old Minimally invasive technique Used for unexplained menorrhagia
when medical treatment are rejected, unsuccessful, or poorly tolerated
Could be hysteroscopic or non-hysteroscopic
Mode of action
Endometrial destruction Use of energy to produce necrosis of
full thickness of endometrium 1st generation: heat, laser 2nd generation:heat,cold, microwave,
suction
Criteria for endometrial ablation
Abnormal uterine bleeding No desire for amenorrhea Unsuccessful medical treatment Endometrial biopsy negative for atypia
and cancer Family complete
Exclusion criteria
Coexisting gynecological pathology Endometria atypia and cancer Submucous fibroids> 5cm Uterus more than 12 weeks in size Anovulation, endometrial hyperplasia
First generation
Roller ball ablation Loop endometrial section Laser ablation
First generation
Used in operating theatre under GA A non-ionic, low viscosity fluid (1.5%
glycine) used for uterine distention Fluid overload is possible
Long term risks
Post ablation pregnancy Hematometra from cervical stenosis Uterine synechiae Occult endometrial carcinoma
2 direct deaths reported in the MISTLETOE study* (10,686 women)
*Overton et al BJOG 19997;104:1351
First generation
Neither of the methods can guarantee sterility
Risk of uterine perforation is greatest at the uterine cornu as the myometriun is thinnest
Hormonal preparation not necessary prior to loop resection
Use of bipolar for endometrial resection improves safety
First generation
Take biopsy prior to roller ball or laser Success and safety is dependent on
the experience of the surgeon
Second generation
Cryotherapy Fluid balloon Microwave ablation Electrode Hydrothermoblation Laser interstitial hyperthermy Photodynamic therapy
Second generation
Different devices vary in their ability to treat non standard uteri
2nd generation devices show no difference in the short term outcomes, patient satisfaction (MISTLETOE study)
Lacking RCTs on the cost effectiveness of this methods and safety
Overton et al BJOG 19997;104:1351
Role of GnRH agonists
Can achieve short-term relief from a bleeding problem
Preoperatively adjunct in women awaiting surgery
Prior to endometrial ablation
Doctor which is the best method for me?
‘....make the operation/treatment suit the patient, rather than the patient suit the operation…’ Dr. Charles Mayo
LNG-IUS or Hysterectomy
Clinical outcomes and costs: Randomised trial 5-year
follow-up
JAMA 2004; 291(12): 1456-63
JAMA. 2004; 291:1456-1463
Hurkainen R. JAMA. 2004;294:1456
Conclusion
LNG-IUS Provides improvement in health related
quality of life at a relatively low cost May decrease costs due to interventions
involving surgery
LNG or hysterectomy
Fall in Gyne surgery with the rise in use of IUS in Newcastle upon Tyne
LNG-IUS vs Endometrial ablation
Lower PBAC with ablation No difference in amenorrhea Comparable rates of satisfaction No difference in the requirement for
further surgery
Conhrane review 2007, issue 4. CD001501
The Medicine or Surgery (Ms) trial
Effect of hysterectomy on Health-Related Quality of Life and Sexual Functioning
JAMA. 2004; 291: 1447-1455
Copyright restrictions may apply.
Kuppermann, M. et al. JAMA 2004;291:1447-1455.
MCS and PCS scores Over Time
Copyright restrictions may apply.
Kuppermann, M. et al. JAMA 2004;291:1447-1455.
MCS and PCS Over Time
Conclusions
Hysterectomy improved HRQL after 6 months
Half of the women on medical treatment eventually opt for surgery later
HRQL is similar despite these between the two groups.
Endometrial ablation vs Hysterectomy
Hysterectomy Reduced HMB High satisfaction Improvement in
general health Higher costs
Ablation Less duration of
surgery Quicker recovery Less complications Higher rates of
repeat surgery
Conhrane review 2007, issue 4. CD000329
Complications of hysterectomy
The Vaginal Abdominal or Laparoscopic Uterine Excision
(VALUE) Study
BJOG 2004; Vol 111: 688-694.
Interaction of risk of severe complications between indication and age
Interaction of risk of severe complications by method and age
Conclusions
Severe complications are more common in younger women.
Less invasive options should be considered
They could effectively replace hysterectomy
“…Daughter, your faith has healed you. Go in peace…"
Thank you