Tired of Abnormal Vaginal Bleeding? Springfield Clinic


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Tired of Abnormal Vaginal Bleeding? Endometrial Ablation to the Rescue, presented by Richard Eden MD, Obstetrics and Gynecology, Springfield Clinic.

Originally presented at Springfield Clinic Me 1st Women's Health Event, May 2010 - All information and images provided by presenter.

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  • Bone loss with depo provera is about 3-5% for 2-4 yrs of use. It returns to baseline bone density within 24-30 months. Pregnancy is associated with a 2-8% bone loss. Breast feeding is associated with 3-5% bone loss rare as well. In teenage years bone lose is about 3% for a 2 yr period.
  • Endometrial biopsy is a safe, relatively simple procedure that can be performed during the initial office visit. It is widely used for excluding endometrial cancer, especially in peri- and postmenopausal women. A biopsy may also be used to determine if the bleeding is ovulatory or anovulatory. A drawback to the utility of endometrial biopsy is that it is not a sensitive technique for detecting structural abnormalities, such as polyps or fibroids. Several techniques may be used to obtain endometrial samples. Unfortunately, hospital-based D&C is still performed—even though it should be discouraged. It is no longer considered the gold standard for evaluation of abnormal bleeding, except in patients who have had a miscarriage. A diagnostic D&C is highly inaccurate, resulting in missed diagnoses and incomplete removal of intracavitary pathologic tissue, and is associated with a high false-negative rate. A recently reported retrospective study demonstrated that D&C failed to detect intrauterine disorders in 248 of 397 (62.5%) women. Office-based sampling techniques have been shown to be at least equivalent to D&C in sensitivity and rate of positive diagnosis/effectiveness, while being less intrusive and more cost-effective. Several sampling devices are available for office-based endometrial biopsy, including disposable devices (eg, Pipelle, Tis-u-Trap, Accurette, Z-sampler) and reusable instruments (eg, Novak Curette, Randall Curette, Vabra Aspirator).
  • TVS is inexpensive, noninvasive, and a convenient technique for indirectly visualizing the endometrial cavity, myometrium, and adnexa, and measuring endometrial thickness. It may be used to identify possible abnormal endometrial conditions, such as atrophy, hyperplasia, cancer, leiomyomas, and polyps. Normally, the postmenopausal endometrial echo measures less than 5 mm. Fewer than 0.5% of women with an endometrial echo less than 5 mm will have endometrial cancer. Thicknesses greater than 5 mm are associated with endometrial hyperplasia, polyps, submucosal fibroids, and endometrial cancer. Even through the endometrium is thicker in women receiving HRT, a thin endometrial echo has high negative predictive value for endometrial cancer. Limitations of TVS may include problems associated with poor body habitus, skill of the operator, low signal-to-noise ratio, and lack of tissue-characterization. TVS may not always distinguish among a submucosal fibroid, endometrial polyp, or adenomyosis.
  • This slide shows a TVS image of a posterior fibroid. Slide courtesy of Linda Darlene Bradley, MD.
  • Saline infusion sonography (SIS) is a relatively new technique that involves the infusion of saline into the endometrial cavity to enhance the detection of abnormalities. This technique is very useful for the evaluation of abnormal bleeding in pre-, peri-, and postmenopausal women. It has been reported that SIS is superior to TVS alone for evaluating the uterine cavity in patients with abnormal uterine bleeding. When used in conjunction with endometrial biopsy for the evaluation of postmenopausal women with abnormal uterine bleeding, SIS may have a sensitivity of 95% to 96.2% and a specificity of 65.7% to 98% for the detection of abnormal endometrial tissue. A reported disadvantage of SIS is that small irregularities caused by blood clots or endometrial protrusions have been frequently misinterpreted as polyps.
  • This slide shows a SIS image of a posterior Class 3 fibroid abutting the posterior endometrium. Slide courtesy of Linda Darlene Bradley, MD.
  • This slide shows a transvaginal saline infusion sonography (SIS) of a submucosal fibroid. The fibroid can be clearly delineated and seen to be protruding into the endometrial cavity.
  • This slide shows an SIS image of endometrial polyps. Slide courtesy of Linda Darlene Bradley, MD.
  • Hysteroscopy with biopsy allows visualization of the endometrial cavity, and this technique has been regarded as the “gold standard” for endometrial assessment. Most hysteroscopies are performed to evaluate abnormal uterine bleeding—up to 60% in one author’s experience. Diagnostic hysteroscopy can now be performed easily in an office setting, requires minimal anesthesia or sedation, and allows detection of endometrial myomas, polyps, and other lesions that may cause bleeding. Diagnostic hysteroscopy is particularly useful in the diagnosis of intrauterine lesions in women of reproductive age with ovulatory AUB. Office-based diagnostic hysteroscopy has been associated with a low ( <1%) incidence of complications when performed by physicians skilled in the technique. Complications may include uterine perforation, infections, excessive bleeding, and complications related to the distending medium (eg, CO 2 embolus). The major disadvantages of office-based hysteroscopy include the cost and maintenance of expensive equipment (eg, camera, insufflator, hysteroscope, video equipment), the skill and training required to perform the procedure, and the cost of the procedure.
  • This slide shows a hysteroscopic image of the endometrial polyps seen on the SIS in the previous slide. Slide courtesy of Linda Darlene Bradley, MD.
  • This slide shows four hysteroscopic images of endometrial polyps. Slide courtesy of Linda Darlene Bradley, MD.
  • This slide shows multifocal endometrial hyperplasia. Slide courtesy of Linda Darlene Bradley, MD.
  • Hysteroscopic view of electrosurgical endometrial resection. The resection loop is seen in distance. Normal endometrium is on the the right and a recently resected section is on the left.. Slide courtesy of Raymond W. Ke, MD.
  • If myometrium is < 10 mm thick then increased risk of transmural thermal injury to intraabdominal organs.
  • This slide presents data reported for the ThermaChoice® Uterine Balloon Therapy System, Hydro ThermAblator® Endometrial Ablation System, Her Option™ Uterine Cryoablation Therapy™ System, and the NovaSure™ System. The data presented here were collected for intent-to-treat groups from separate studies as reported in FDA Summary of Safety and Effectiveness Data (SSED) for each device. These data do not reflect head-to-head comparison of the devices, so caution should be used when comparing efficacy of the devices based on these data.
  • Tired of Abnormal Vaginal Bleeding? Springfield Clinic

    1. 1. Excessive Vaginal Bleeding What to do about it? Richard T. Eden, M.D. OB/GYN Springfield Clinic Springfield,IL
    2. 2. Normal Menses <ul><li> Normal Abnormal </li></ul><ul><li>Duration of flow 4-6 days >7days </li></ul><ul><li>Volume of flow 35 ml >80 ml </li></ul><ul><li>Length of cycle 21-35 days </li></ul>
    3. 3. Abnormal Uterine Bleeding Affects… <ul><li>Adolescents </li></ul><ul><li>Women of reproductive age </li></ul><ul><li>Perimenopausal and postmenopausal women </li></ul>
    4. 4. Menorrhagia Excessive Menstrual Bleeding Endometrium Myometrium Cervix <ul><li>Abnormal bleeding is defined by: </li></ul><ul><li>Length of cycle (days) </li></ul><ul><li>Duration of menses (days) </li></ul><ul><li>Amount of blood loss (ml) </li></ul>
    5. 5. Abnormal Uterine Bleeding Definitions <ul><li>Menorrhagia -heavy or prolonged uterine bleeding that occurs at regular intervals. Usually >7d or >80 ml blood loss. </li></ul><ul><li>Oligomenorrhea -cycle length >35 days </li></ul><ul><li>Polymenorrhea -cycle length < 21days </li></ul><ul><li>Amenorrhea -absence of menstruation for at least 6 months. </li></ul><ul><li>Metrorrhagia -irregular menstrual bleeding or bleeding between periods. Usually normal or reduced flow. </li></ul><ul><li>Menometrorrhagia -irregular menstrual bleeding with excessive volume and duration of flow. </li></ul>
    6. 6. Uterus <ul><li>Hollow, pear-shaped muscular organ, which lies in the pelvic cavity, between the urinary bladder and the rectum </li></ul><ul><li>Functions to prepare for and maintain pregnancy </li></ul>
    7. 7. Laparoscopy-Normal Uterus
    8. 8. Normal Uterus & Right Ovary/Tube
    9. 9. Normal Uterus & Left Ovary/Tube
    10. 10. Abnormal Uterine Bleeding <ul><li>Affects >10 million women in the U.S. </li></ul><ul><li>Impacts daily activities and quality of life </li></ul><ul><li>May cause anxiety </li></ul><ul><li>May lead to iron-deficiency anemia/fatigue </li></ul>
    11. 11. Normal Menstrual Cycle
    12. 12. Abnormal Uterine Bleeding Differential Diagnosis <ul><li>Structural </li></ul><ul><ul><li>-Cervical or vaginal laceration </li></ul></ul><ul><ul><li>-Uterine or cervical polyp </li></ul></ul><ul><ul><li>-Uterine leiomyoma (fibroids) </li></ul></ul><ul><ul><li>-Adenomyosis </li></ul></ul><ul><ul><li>-Cervical stenosis/Asherman’s (hypomenorrhea) </li></ul></ul>
    13. 13. Abnormal Uterine Bleeding Differential Diagnosis <ul><li>Hormonal </li></ul><ul><li>-Anovulatory bleeding (lack of ovulation-decreased progesterone) </li></ul><ul><li>-Hypogonadotropic hypogonadism </li></ul><ul><li>-Pregnancy </li></ul><ul><li>-Hormonal contraception (BCP’s, Depo-Provera) </li></ul><ul><li>Malignancy </li></ul><ul><li>-Uterine or Cervical cancer </li></ul><ul><li>-Endometrial hyperplasia (potentially pre-malignant) </li></ul><ul><li>-Chemotherapy or radiation </li></ul><ul><li>Bleeding Disorders </li></ul><ul><li>-VonWillebrand’s Disease, Hemophilia, ITP, Factor </li></ul><ul><li>deficiencies, platelet disorders. </li></ul>
    14. 14. Abnormal Uterine Bleeding Workup <ul><li>History </li></ul><ul><li> -Timing of bleeding, quantity of bleeding, menstrual history, associated symptoms. </li></ul><ul><li>Family history of bleeding disorders. Excessive psychological stress, exercise, or weight loss. </li></ul><ul><li>Physical Exam </li></ul><ul><li>-pap smear (rule out cervical cancer) </li></ul><ul><li>-endometrial biopsy (rule out uterine cancer) </li></ul><ul><li>-excessive facial hair growth, obesity (BMI>25) (polycystic ovarian disease 6-10% of women) </li></ul><ul><li>-abnormal breast discharge (prolactin disorders) </li></ul><ul><li>-anorexia signs (hypothalamic dysfunction) </li></ul><ul><li>-goiter, weight loss or gain (thyroid disease) </li></ul><ul><li>-other disease states (leukemia, hypersplenism, chemo, radiation) </li></ul><ul><li>Labs </li></ul><ul><li>-Pregnancy test </li></ul><ul><li>-FSH, LH, Estradiol </li></ul><ul><li>-TSH, Prolactin, DHEA-S, Testosterone </li></ul><ul><li>Imaging </li></ul><ul><li>-Pelvic ultrasound (transvaginal) </li></ul><ul><li>-Sonohystogram (saline infusion ultrasound) or hysterosalpingogram (x-ray) </li></ul><ul><li>-MRI (better for adenomyosis dx than U/S) </li></ul><ul><li>Surgical </li></ul><ul><li>-Hysteroscopy </li></ul><ul><li>-D&C </li></ul>
    15. 15. Medical Treatment of Abnormal Uterine Bleeding <ul><li>Iron </li></ul><ul><li>NSAID’s </li></ul><ul><li>Combined Contraceptives (estrogen and progesterone) </li></ul><ul><li>Progesterone only methods </li></ul><ul><li>IV Estrogen </li></ul><ul><li>GnRH agonists </li></ul><ul><li>Androgens </li></ul><ul><li>Antiprogestational agents </li></ul>
    16. 16. Iron <ul><li>Menstrual volume > 60 ml- iron deficiency anemia </li></ul><ul><li>Primary symptom is fatigue </li></ul><ul><li>Daily doses of 60-180 mg of iron needed for anemia Rx </li></ul><ul><li>May be the only treatment necessary </li></ul>
    17. 17. NSAID’s <ul><li>Nonsteroidal Anti-inflammatory Drugs </li></ul><ul><li>Can decrease bleeding by 30-40% </li></ul><ul><li>Motrin (ibuprofen) 400mg every 4 hrs </li></ul><ul><li>Anaprox (Naproxen) 550 mg every 12 hrs </li></ul>
    18. 18. Combined Contraceptives <ul><li>Contain both estrogen & progesterone </li></ul><ul><li>Birth control pills (daily) </li></ul><ul><li>Birth control patch Ortho Evra (weekly) </li></ul><ul><li>Contraceptive ring Nuvaring (monthly) </li></ul>
    19. 19. NuvaRing
    20. 20. Progesterone only Methods <ul><li>Mini-pill -often used in breastfeeding moms, useful in patients who cannot take estrogen containing pills (Hx of strokes, DVT’s, breast cancer). </li></ul><ul><li>Depo-Provera -3 month birth control, high amenorrhea rate, causes weight gain, causes increased bone loss. </li></ul><ul><li>Progesterone sub dermal implants (Implanon) -3 year birth control. High irregular bleeding rates during the first few months. </li></ul><ul><li>Progesterone IUD (Mirena) -5 year birth control, 70-80% reduction in blood loss, 99.8% effective contraception, 3-5 minute office procedure. Same bleeding rate control as ablations after 2-3 years of use. </li></ul>
    21. 21. Implanon
    22. 22. Mirena IUD
    23. 23. Other treatments <ul><li>IV Estrogen —stops bleeding acutely (71% bleeding cessation vs. 38% placebo), usually within 24-48 hrs, given in hospital setting. Premarin 25 mg IV q 4 hrs x 24 hrs. </li></ul><ul><li>Lupron (GnRH agonist) —induces amenorrhea in 40-60% of patients by shrinking total uterine volume. Limited use due to cost and “menopause-like” side effects. Mostly used for fibroid related bleeding prior to surgery. </li></ul><ul><li>Androgens (Danazol) —synthetic testosterone derivative, reduces bleeding volume 50% in women with ovulatory bleeding. Side effects make long term treatment undesirable. </li></ul><ul><li>Antiprogestational Agents (Mifepristone 50 mg/day) —reduces the number of progesterone receptors in the uterus. Reported to induce amenorrhea in women with fibroids. </li></ul>
    24. 24. Endometrial Ablation <ul><li>Surgical procedure-outpatient surgical setting, usually general anesthesia. </li></ul><ul><li>Indicated for the treatment of menorrhagia or perceived heavy menstrual bleeding in premenopausal women (usually< age 50). </li></ul><ul><li>Presence of anemia or failed medical therapy are other indications for endometrial ablations. </li></ul><ul><li>Goal is to normalize menstrual blood flow. </li></ul><ul><li>Contraindicated in postmenopausal bleeding patients. </li></ul><ul><li>Not a contraceptive method. </li></ul><ul><li>Must be done with childbearing (previous tubal or vasectomy). </li></ul><ul><li>Tubal ligation can be done the same day as the ablation surgery. </li></ul>
    25. 25. Ablation Preoperative Evaluation <ul><li>Pap smear -used to exclude cervical cancer </li></ul><ul><li>Endometrial biopsy -used to exclude uterine cancer or uterine hyperplasia. </li></ul><ul><li>Transvaginal U/S -used to look for anatomic causes of bleeding such as uterine fibroids, uterine polyps, cervical polyps, or congenital malformations of the uterus (septate uterus). Often combined with saline infusion sonography (SIS). </li></ul><ul><li>Hysteroscopy -using a camera to look “inside” the uterine cavity. </li></ul><ul><li>D&C –dilation & curettage-scrapping uterine lining. </li></ul>
    26. 26. Endometrial Biopsy <ul><li>Safe, relatively simple procedure useful in perimenopausal or high risk women </li></ul><ul><li>Not sensitive for detecting structural abnormalities (eg, polyps or fibroids) </li></ul><ul><li>Office-based techniques (gold standard replacing D&C) </li></ul><ul><ul><li>Disposable devices (eg, Pipelle, Tis-u-Trap, Accurette, Z-sampler) </li></ul></ul><ul><ul><li>Reusable instruments (eg, Novak Curette, Randall Curette, Vabra Aspirator) </li></ul></ul>
    27. 27. Transvaginal Ultrasonography (TVS) <ul><li>Inexpensive, noninvasive, and convenient </li></ul><ul><li>Indirect visualization of the endometrial cavity, myometrium, and adnexa </li></ul><ul><li>Measurement of endometrial thickness ( <5 mm vs. >5 mm) </li></ul><ul><li>May be used to increase index of suspicion for endometrial atrophy, hyperplasia, cancer, leiomyomas, and polyps </li></ul><ul><li>May not always distinguish among submucosal fibroid, polyp, or adenomyosis </li></ul>
    28. 28. Posterior Fibroid Slide courtesy of Linda Darlene Bradley, MD.
    29. 29. Saline Infusion Sonography (SIS) <ul><li>Relatively new technique </li></ul><ul><li>Very useful for evaluation of AUB in pre-, peri-, and postmenopausal women </li></ul><ul><li>May be superior to TVS alone (94.1% vs. 23.5% for detection of focal intrauterine pathology) </li></ul><ul><li>SIS + biopsy: 96.2% sensitivity and 98% specificity </li></ul><ul><li>Disadvantage: small irregularities may be misinterpreted as polyps </li></ul><ul><li>Able to determine penetration depth of uterine fibroids </li></ul>
    30. 30. Saline Infusion Sonography
    31. 31. Posterior Fibroid Slide courtesy of Linda Darlene Bradley, MD.
    32. 32. Submucosal Fibroid Slide courtesy of Raymond W. Ke, MD.
    33. 33. Endometrial Polyps Slide courtesy of Linda Darlene Bradley, MD.
    34. 34. Hysteroscopy <ul><li>Hysteroscopy + biopsy = “gold standard” </li></ul><ul><li>Most are performed to evaluate AUB </li></ul><ul><li>Diagnostic hysteroscopy easily performed in the office setting—although it requires skill </li></ul><ul><li>Particularly useful in the diagnosis of intrauterine lesions in women of reproductive age with ovulatory AUB </li></ul><ul><li>Complications ( <1%) may include uterine perforation, infections, excessive bleeding, and those related to distending medium </li></ul>
    35. 35. Hysteroscopy = Uterine Camera
    36. 36. Flexible hysteroscope
    37. 37. Normal Uterine Cavity
    38. 38. Uterine septum
    39. 39. Endometrial Polyps Slide courtesy of Linda Darlene Bradley, MD.
    40. 40. Vascular endometrial polyp
    41. 41. Endometrial Polyps Slide courtesy of Linda Darlene Bradley, MD.
    42. 42. Uterine Polyp
    43. 43. Uterine Polyps
    44. 44. Uterine Polyp
    45. 45. Large Uterine Polyp
    46. 46. Large Uterine Polyp
    47. 47. Uterine Cavity Post Resection of Polyp
    48. 48. Uterine Polyps
    49. 49. Uterine Polyps
    50. 50. Endometrial Hyperplasia Slide courtesy of Linda Darlene Bradley, MD.
    51. 51. Uterine Submucosal Fibroid
    52. 52. Electrosurgical Endometrial Resection Slide courtesy of Raymond W. Ke, MD.
    53. 53. Resection of uterine fibroid
    54. 54. Ablation Devices <ul><li>Novasure —uses radiofrequency electricity with a bipolar gold mesh electrode. The device is passed through the cervix and into the uterine cavity. </li></ul><ul><li>Ablation cycle takes 80-90 seconds. Very fast. </li></ul><ul><li>78% Success rate </li></ul><ul><li>35-41% amenorrhea rate </li></ul><ul><li>92% patient satisfaction rate at 1 year </li></ul>
    55. 55. Step 1 After slightly dilating your cervix and inserting a slender wand, your doctor will extend a triangular mesh device into your uterus.
    56. 56. Step 2 The mesh device gently expands, conforming to the dimensions of your uterine cavity.
    57. 57. Step 3 Electrical energy is delivered through the mesh for approximately 90 seconds.
    58. 58. Step 4 The mesh device is retracted back into the wand and both are removed from your uterus.
    59. 59. Novasure Endometrial Ablation
    60. 60. Endometrial Ablation
    61. 61. Novasure Endometrial Ablation
    62. 62. Thermachoice Endometrial Balloon
    63. 63. Ablation Devices <ul><li>Thermachoice —balloon tipped catheter is positioned into the uterine cavity and filled with fluid that is heated to 87 degrees centigrade. </li></ul><ul><li>Ablation cycle takes 8 minutes. </li></ul><ul><li>May be better suited for fibroid uterus. </li></ul><ul><li>Reported to decrease menstrual cramps better. </li></ul><ul><li>80 % success rate </li></ul><ul><li>37% amenorrhea rate at one year </li></ul><ul><li>96% patient satisfaction rate </li></ul>
    64. 64. Ablation Complications <ul><li>UTI 0.8-3 % </li></ul><ul><li>Vaginal infection 0.6-2.3% </li></ul><ul><li>Fever 1.4% </li></ul><ul><li>Endometritis 1-2.8 % </li></ul><ul><li>Abdominal pain/cramps 0.6-3.2% </li></ul><ul><li>Hematometra 0.6 % </li></ul><ul><li>Bacteremia 0.5% </li></ul><ul><li>Uterine perforations 1.4% </li></ul><ul><li>Fluid overload 0.2% </li></ul><ul><li>Postablation tubal ligation syndrome 1-10% </li></ul><ul><li>Electrolyte imbalance </li></ul><ul><li>Cervical laceration </li></ul>
    65. 65. Contraindicatons to Ablation <ul><li>Large uterus > 12 wks size </li></ul><ul><li>Uterine fibroids > 3 cm </li></ul><ul><li>Uterine cancer or uterine hyperplasia </li></ul><ul><li>Postmenopausal females </li></ul><ul><li>Recent pregnancy (must be at least 6 wks postpartum) </li></ul><ul><li>Desire for future pregnancy </li></ul><ul><li>Active or recent uterine infection (PID) </li></ul><ul><li>Previous uterine surgery (C/S or myomectomy) </li></ul><ul><li>Anatomic distortion (congenital uterine malformations—bicornuate uterus, etc.) </li></ul>
    66. 66. Effectiveness of Ablation <ul><li>>90 % patient satisfaction at 1 year </li></ul><ul><li>37-41% amenorrhea rate </li></ul><ul><li>About 10% dissatisfaction rate at one year </li></ul><ul><li>2-3 % have repeat ablations after one year </li></ul><ul><li>6-10% will have subsequent hysterectomy after one year </li></ul><ul><li>Some studies report 8% to 24% subsequent hysterectomy rates at 7 years post ablation </li></ul>
    67. 67. Hysterectomy <ul><li>Total abdominal hysterectomy (TAH) </li></ul><ul><li>Vaginal hysterectomy </li></ul><ul><li>Laparoscopic assisted vaginal hysterectomy (LAVH) </li></ul><ul><li>Laparoscopic supracervical hysterectomy (LSH) </li></ul><ul><li>Total laparoscopic hysterectomy (TLH) </li></ul>
    68. 68. Endometrial Ablation Summary <ul><li>Endometrial ablations are effective treatment for abnormal uterine bleeding </li></ul><ul><li>Outpatient procedure </li></ul><ul><li>>90% patient satisfaction rate </li></ul><ul><li>High amenorrhea rate </li></ul><ul><li>Estimated that endometrial ablations will replace 30% of all hysterectomies done in U.S. </li></ul>
    69. 69. My Girls
    70. 70. Endometrial Ablation Techniques: Reported Data