Perimenopausal bleeding

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comprehensive evaluation of perimenopausal bleeding helps to save uterus and helps patient to receive specific treatment

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Perimenopausal bleeding

  1. 1. Perimenopausal bleeding comprehensive evaluation to save uterus. Veerendrakumar CM MD.,DNB Professor Dept of OBG,VIMS,Bellary. 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 1
  2. 2. READ/LISTEN/TALK to  Not to contradict & Confute. Nor to believe & take it for granted. Nor to find & discourse. But to weigh & consider. Francis Bacon 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 2
  3. 3. Litigant and evidence based world.. Don’t simply knock off the uterus.  Uterus is a marker of FEMINITY.  Make all efforts to save it   Comprehensive evaluation can offer specific treatment. 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 3
  4. 4. Perimenopausal bleeding  It is 3-5 years period before menopause with increase frequent irregular anovulatory bleeding followed by episodes of ammenorrhea and intermittent menopausal symptoms. 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 4
  5. 5. low resource …  basic investigations for abnormal uterine bleeding (AUB) – bearing in mind issues of effectiveness and cost effectiveness. 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 5
  6. 6.  Ideally, the evaluation is comprehensive, considering each of the potential etiological domains as defined by FIGO PALM-COEIN system for Causes. International Journal of Gynecology and Obstetrics 113 (2011) 3–13 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 6
  7. 7. Figo classification of causes of AUB 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 7
  8. 8.  the extent of investigations will be significantly influenced by the technologies available and the time allotted for a consultation. 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 8
  9. 9.  investigations should be performed only if they will make a material difference to the management approaches that can be offered. 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 9
  10. 10. AUB  heavy menstrual bleeding (HMB), intermenstrual bleeding (IMB), and irregular menstrual bleeding are very common. Semin Reprod Med 2011;29(5):383–390 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 10
  11. 11. Medications that can be associated with abnormal uterine bleeding Anticoagulants  Antidepressants (SSRIand tricyclics)  Hormonal contraceptives  Tamoxifen  Antipsychotics  Corticosteroids  Herbs: ginseng,chasteberry,danshen  11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 11
  12. 12. Systematic investigation  Determination of the clinical impact of the symptom with HMB  Evaluation of the patient for the underlying cause 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 12
  13. 13. Assesmeent of blood loss.. Frequency of changing "menstrual protection" items, use of "double" protection;  changing menstrual protection at night; selfconsciousness about odor; inability to contain "gushes" of menstrual  flow; embarrassment at being unable to contain "gushes" of flow, and preparations and rituals to prevent embarrassing episodes.  NICE Guideline 44; Heavy menstrual bleeding. Women Health 2010;50(2): 195–211 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 13
  14. 14. Pelvic examination  pelvic signs are picked up with low sensitivity and specificity in most situations, especially when influenced by obesity and the nervous patient. postgraduate training improves the accuracy of this examination, Int J Gynaecol Obstet 2005;88(1):84–88  it is of great value in the evaluation of the cervix. 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 14
  15. 15. Labortatory assesment  Evaluation for coagulopathies that may contribute to HMB (AUB-C) is important in any setting Ann Hematol 2005;84(5):339–342 Fertil Steril 2005;84(5):1345–1351 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 15
  16. 16. Acquire knowledge and clinical skills to Comprehensively evaluate the uterus 1. assessment of the endometrium for the presence of hyperplasia or malignancy; 2.visualization of the endometrial cavity and cervical canal for localized Lesions and 3.evaluation of the structure of the uterine wall for adenomyosis, leiomyomas, and, more rarely, arteriovenous malformations. Semin Reprod Med 2011;29(5):391–399 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 16
  17. 17. Ultrasound  TVUS is undoubtedly the primary imaging modality  highly dependent on the skill and experience of the ultrasound operator and contemporary machine !!! 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 17
  18. 18. TVUS  …an excellent tool for the determination of whether further investigation with curettage or some form of endometrial biopsy is necessary Am J Obstet Gynecol. 2003 Feb;188(2):401-8. 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 18
  19. 19. Typically, endometrial thickness is actually measured and reported as the sum of the two adjacent layers of endometrium, in essence a double thickness, a measurement called  the Endometrial Echo Complex, or EEC. 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 19
  20. 20. as long as the EEC thickness is ≤12 mm (in premenopausal women), there is a very low incidence of endometrial hyperplasia or neoplasia.  Ultrasound Obstet Gynecol 1998;11(5):337–342 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 20
  21. 21. Who should undergo endometrial sampling?        AUB and an EEC >12 mm should be sampled. age >45 years; obesity (>90 kg) a history of chronic anovulation, infertility, or diabetes; a family history of endometrial cancer; and prolonged exposure to unopposed estrogens or tamoxifen. Am J Obstet Gynecol 1999;181(3):525–529  Colorectal cancer affected families with AUB regardless of age 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 21
  22. 22. Endometrial sampling  Histological assessment of the endometrium requires a biopsy or curettage to evaluate for endometrial hyperplasia or malignancy (AUB-M). 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 22
  23. 23.  Office endometrial sampling has a reasonably high accuracy and detects 67 to 96% of endometrial carcinomas.  J Reprod Med 1995;40(8):553–555 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 23
  24. 24.  insufficient tissue obtained for diagnosis has been reported in 4 to 20% of cases. Gynecol Obstet Invest 1994;37(4):260–262 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 24
  25. 25. D and C left to Oblivion ??? 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 25
  26. 26. Récamier's operation ( D &C ) named after French gynecologist who designed curette. 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 26
  27. 27. Options D&C Endomet biopsy USG Hysteroscopy 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 27
  28. 28. Dilatation and curettage alone should not be used as a diagnostic tool. suggested that D&C does not give additional diagnostic information over and above a hysteroscopy with endometrial biopsy and it is not therapeutic in cases of heavy menstrual bleeding  NICE clinical guideline 44 11/14/2013 Heavy menstrual bleeding Prof.Veerendrakumar,VIMS, Bellary. 28
  29. 29.  D&C should no longer be used as the first-line method of investigating PMB in most cases.  Scottish Intercollegiate Guidelines 2011 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 29
  30. 30.  it is limited in its ability to access the tubal cornua of the uterus.  Hysteroscopy with biopsy provides more information than dilatation and curettage alone and rivals the combination of salineinfusion sonohysterography and endometrial biopsy in its ability to diagnose polyps, submucous fibroids, and other sources of abnormal uterine bleeding. Am Fam Physician. 2004 Apr 15;69(8):1915-1926. 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 30
  31. 31.  Hysteroscopy with directed biopsy is more sensitive in disclosing all types of uterine lesions than dilatation and curettage.  Curettage done after hysteroscopy and directed biopsy does not improve the detection of endometrial cancer Eur J Gynaecol Oncol. 2007;28(5):400-2. 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 31
  32. 32.  We support hysteroscopy as a routine alternative to dilatation and curettage in the diagnosis of postmenopausal bleeding J Obstet Gynaecol. 2001 Jan;21(1):67-9 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 32
  33. 33. 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 33
  34. 34. D&C missed 58% (25/43) of polyps,  50% (5/10) of hyperplasias,  60% (3/5) of complex atypical Hyperplasias, and  11% (2/19) of endometrial cancers.  11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 34
  35. 35.   The limitations of D&C are due to the blindness of the sampling procedure. George Vorgias,etal 10/14/2003; Medscape General Medicine. 003;5(4) 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 35
  36. 36.  dilatation a  YOU SHOULD NOT BE OFFERED…  oral progestogens for use only in the second half of your menstrual cycle  drugs called danazol and etamsylate D and C, which involves scraping out the womb lining – as a treatment or test on its own 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 36
  37. 37. Endometrial Biopsy (EMB) Safe, simple office procedure 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 37
  38. 38. Both EB and D& C  ineffective at diagnosing focal lesions. Polyps (AUB-P) are frequently missed (up to 50%) by blind techniques, which may include cases of focal atypical hyperplasia and carcinoma especially in premenopausal cases. Cancer 2000;89(8):1765–1772 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 38
  39. 39. Structural abnormalities P –Polyp  A-Adenomyosis  L-Leiomyoma  M-Malignancy- endometrial hyperplasia and endometrial carcinoma.  11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 39
  40. 40.  advanced TVUS developments have improved our ability to detect and define certain structural lesions. -saline infusion sonography (SIS), -color-flow Doppler assessment, and -3D imaging techniques. 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 40
  41. 41. Endometrial Polyp 3D Ultrasound 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 41
  42. 42. Saline infusion sonogram (SIS) Sonohysterography.  Hysterosonography,  Transvaginal sonography (TVS) with fluid contrast augmentation  Saline infusion sonogram (SIS)  Parson, J Clin Ultrasound 1993 Goldstein J Ultrasound Med 2001; 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 42
  43. 43. SIS      Performed during proliferative phase Not later than 10 days Post menopuasal bleeding – any time Women on HRT time it during withdrawal or during progesterone phase Bleeding not a contraindication but clot can make interpretation difficult. But doppler can differentiate cavitory lesions. ‘standard for the performance of saline infusion sonohysterography. J Ultrasound Med 2003 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 43
  44. 44. SIS If a focal lesion is identified on SIS, that lesion can be treated with hysteroscopy.  Those patients who do not have a focal lesion can be spared hysteroscopy in many cases.  11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 44
  45. 45. meta-analysis of 5892 women.  Using a double-wall thickness of 5 mm,the sensitivity for detecting endometrial cancer was 96%  A thin endometrium of 5 mm or less had a high negative predictive value, and this finding would support the diagnosis of atrophy JAMA 1998; 280:1510–1517. 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 45
  46. 46. Pipelle curette is “excellent for detecting endometrial processes when the pathology is global in nature.”  When a focal lesion is detected a visually directed biopsy is indicated.  J Reprod Med 1995; 40:553–555. 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 46
  47. 47.  In postmenopausal women, polyps are found to be the cause of bleeding in approximately 30% of cases. Most of these polyps are benign.  malignancy in polyps ranges from 0.5% to 1.5%.   Eur J Gynaecol Oncol 2000; 21:180–183. 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 47
  48. 48.  Transvaginal sonography cannot distinguish endometrial hyperplasia from benign polyps  both conditions can cause thickening of the endometrium, are hyperechoic, and can contain cystic spaces. 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 48
  49. 49. Saline infusion sonohysterography  can distinguish focal lesions from diffuse endometrial thickening. Polyps are focal lesions, which project into the lumen of the endometrial cavity 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 49
  50. 50. Normal endometrium 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 50
  51. 51. Endometrial polyp 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 51
  52. 52. Multiple polyps Longitudinal section Transverse section 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 52
  53. 53. Sub mucous fibroid & polyp 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 53
  54. 54. Blood clot in the cavity After dislodging with the catheter 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 54
  55. 55.  If the fibroid projects into the lumen by more than 50% of its surface, then it can be resected by hysteroscopy, obviating an abdominal surgical procedure 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 55
  56. 56. Endometrial hyperplasia 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 56
  57. 57. SIS for monitoring the pts on Tamoxifen  the finding of a normal endometrium on SIS allowed these patients to avoid further intervention. Am J Roentgenol 1997; 168:657–661. 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 57
  58. 58. Future direction  Endometrial biopsy with real time usg guidance Dubinsky AJR Am J Roentgenol 2000 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 58
  59. 59. SIS  Saline infusion sonohysterography is a simple technique that yields additional information over TVS in evaluation of endometrial and subendometrial conditions. 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 59
  60. 60. Clinical impact SIS added certainty to the diagnosis in 88% of the patients studied.  SIS results changed the patients’ treatment in 80% of cases.  increased diagnostic confidence by 86%.  Radiology 2000; 216:260–264. 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 60
  61. 61. hysteroscopy  In the presence of an abnormally thick endometrium, when myomas exist suspiciously close to the EEC or when abnormal bleeding occurs or persists despite a normal TVUS, hysteroscopy is indicated. 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 61
  62. 62.  Endometrial carcinoma and endometrial hyperplasia (AUB-M), especially those arising as a field defect, may not always be clearly recognizable by hysteroscope alone, which should be performed in conjunction with endometrial biopsy.  Am J Obstet Gynecol 2007;196(3):243; e1-e5 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 62
  63. 63. SIS v/s Hysteroscopy SIS is comparable to hysteroscopy in its sensitivity for the diagnosis of intracavitary polyps and submucosal myomas  In SIS- limited evaluation of the endocervical canal and the inability to concurrently remove selected lesions   Fertil Steril 2010;94(7):2720–2725 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 63
  64. 64. One stop clinic..  Office hysteroscopy may be more cumbersome, involves a steeper learning curve than either TVUS or SIS, and may also be more uncomfortable for the patient.  likely to achieve a primary diagnostic role if narrow, rigid, or flexible scopes are used without anesthesia or only with local cervical anesthesia and with low-pressure saline distension in an "office" situation Clinical practice guidelines..Eur J Obstet Gynecol Reprod Biol 2010; 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 64
  65. 65. Low resource settings.. When TVUS (including SIS) and hysteroscopy are available, it is recommended they be used in complementary fashion.  In this way, hysteroscopy can be used more selectively to exploit its use as a therapeutic tool for the performance of targeted biopsy, polypectomy, or myomectomy.  11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 65
  66. 66. 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 66
  67. 67. 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 67
  68. 68. 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 68
  69. 69. 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 69
  70. 70. Myometrial evaluation TVUS is generally useful for the evaluation of myomas, 3 D may give additional information.  TVUS is quite sensitive for the diagnosis of diffuse adenomyosis.  Color flow Doppler is of value for the detection of  arteriovenous malformations ,vascular hyperplasias and malignancies. And focal adenomyosis.  11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 70
  71. 71. Therapy  Once malignancy and significant pelvic pathology have been ruled out, medical treatment is an effective first-line therapeutic option for abnormal uterine bleeding. 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 71
  72. 72. NSAID reduced menstrual blood loss by 33% to 55% when compared with placebo, without a significant difference in adverse effects.  added benefit of improving dysmenorrhea for up to 70% of patients.  START before the day of menses and continue for 3-5 days.  Cochrane Database Syst Rev 2007; 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 72
  73. 73. Tranexemic acid overall reduction in menstrual blood loss between 40% and 59% from baseline.  1 gram of tranexamic acid taken orally every 6 hours during menstruation, but a single daily dose of 4 grams has also been found to be effective  Intravenous tranexamic acid is available for more acute scenarios, with a dose of 10 mg/kg every 6 hours.  Cochrane Database Syst Rev 2000;4:CD000249. 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 73
  74. 74.  superiority of tranexamic acid to lutealphase progestins and NSAID BMJ 1996;313:579–82  No statistically significant increase in VTE 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 74
  75. 75. Hormonal..  cyclic luteal-phase progestin therapy is significantly less effective in treating “menorrhagia” than NSAIDS, tranexamic acid, or danazol  In contrast, long-cycle, high-dose oral progestins have been shown to reduce menstrual losses for women with heavy menstrual bleeding.  There are no published trials investigating the impact of DMPA on abnormal uterine bleeding 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 75
  76. 76.  Woman has never learned to live healthy & happy without progesterone coverage of estrogen primed state  Its not simply a Pregnancy Hormone. But in true sense, ‘A Mother Hormone.’ 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 76
  77. 77. LNG-IUS Maximal Benefits Outweigh Minimal Risks.  A reduction in menstrual blood loss of 86% at 3 months and 97% at 12 months was demonstrated in a single-arm study on the use of the LNG-IUS in women with menorrhagia,  20-80% become amenorrhic by 12 months. 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 77
  78. 78.  Hurskainen et al. randomized women with menorrhagia to receive either a hysterectomy or insertion of the LNG-IUS. The two groups had similar health-related quality of life scores at 5 years. JAMA 2004;291:1456–63.  women awaiting hysterectomy, Over two thirds of the women who had the LNGIUS inserted cancelled their surgery versus just 14.3% in the control group. BMJ 1998 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 78
  79. 79.  Danazol and gonadotropin-releasing hormone agonists will effectively reduce menstrual bleeding, and may be used for scenarios in which other medical or surgical treatments have failed or are contraindicated. (I-C). 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 79
  80. 80. SERM’s – The Designer Estrogens  SERMs are designed to act in a specific ways at each of the receptor sites  J Clin Oncol 2000 18:3172-3186. Estrogens SERMs Tomoxifine Droloxifine Toremifine Raloxifine Ormeloxifine Antiestrogens J Clin Oncol 2000 18:3172-3186. 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 80
  81. 81. Ideal SERM for DUB  No uterine stimulation  Prevents bone loss  Has no risk for breast cancer  Has a positive effect on lipids & cardiovascular system  Maintains cognitive function of the brain 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 81
  82. 82. Ormelloxifene 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 82
  83. 83. Weekly twice for 12 weeks weekly once for 12 weeks 74 of 85 subjects (87%) showed a reduction in endometrial thickness Only 8.2% of women needed hysterectomy J Obstet Gynecol Ind vol. 54, No 1 2004 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 83
  84. 84.  Amenorrhea with the therapy – 18 patients (42.9%)  ovarian cyst (7.1%), cervical erosion and discharge (7.1%), gastric dyspepsia (4.8%), vague abdominal pain (4.8%) and headache (4.8%) J. Obstet. Gynaecol. Res. 2009 Ormeloxifene is more effective as compared to MPA in reducing the blood loss in the treatment of DUB. 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 84
  85. 85. Surgical management indications-failure to respond to medical therapy, -inability to utilize medical therapies (i.e. side effects, contraindications), -significant anemia, -impact on quality of life, and -concomitant uterine pathology (large uterine fibroids, endometrial hyperplasia). 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 85
  86. 86. 2nd generation techniques recommended  Several non-hysteroscopic ablation techniques are currently available.  Balloon, microwave, and radiofrequency ablation devices have a large reported clinical experience.  avoids the use of operating room resources and general anaesthetic. SOGC guidelines 2013 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 86
  87. 87. SOGC GUIDELINES 2013 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 87
  88. 88. HYSTERECTOMY THE most definitive treatment.  Consider the least invasive method.  11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 88
  89. 89.  From Research to Practice – Long Way to Go….. Technology made large populations possible and large populations today make technology indispensible 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 89
  90. 90. 11/14/2013 Prof.Veerendrakumar,VIMS, Bellary. 90

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