Abnormal uterine bleeding - Welcome to NHS Networks ... · 16/6/2010 · aModern management of abnormal uterine bleeding (‘AUB’) ... • Significant fibroid uterus (palpable abdominally)

Primary Care Women’s Health Forum

16th June 2010

Abnormal uterine bleeding:The University Of Birmingham

T Justin Clark MD (Hons), MRCOG

Consultant Obstetrician and Gynaecologist Birmingham Women’s HospitalUnited Kingdom

COPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED

AUB

Overview

Modern management of abnormal uterine bleeding (‘AUB’)

Medical Management

Hysteroscopic surgery and fibroid management



16th June 2010

Modern management of AUBThe University Of Birmingham




AUB

What is modern management?

Key features:Efficient, structured and ‘office’ based⌧Patient-care pathways

• Interface between primary and secondary care

⌧Diagnosis• ultrasound

⌧Treatment• Woman-centred; choice; minimally invasive


AUB

Outpatient or ‘office’ procedure:Definition

Outpatient procedures are performed in an appropriate clinic setting, but without the need for formal operating theatre facilities or general anaesthesia.

These clinics are usually within a hospital outpatient department (an ‘outpatient hysteroscopy clinic’), but specific minor operative rooms, other multi-purpose facilities or primary care centres.

“True outpatient procedures” will be discharged unaccompanied within the allocated clinic time and do not require a formal recovery period in a hospital bed.

Justin Clark MD (Hons) MRCOG, Birmingham Women’s HospitalCOPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED

AUB

Primary care setting?

Hospital based (secondary care)Inpatient Day caseDay case Office

This new paradigm has been driven by health technologies and enthusiasts

Primary care:Office Primary care(Office High street)

These concepts can be driven by infrastructure, government and enthusiasts


AUB

Pelvic ultrasound


AUB

Miniaturisation of endoscopes


AUB

Mirena (LNG-IUS)


AUB

Endometrial ablation

Various devicesTwo that I use in both the inpatient and outpatient setting

Justin Clark MD (Hons) MRCOGBirmingham Women’s Hospital


AUB

Enthusiasts.........



AUB

Primary care setting?

Hospital based (secondary care)Inpatient Day caseDay case Office

This new paradigm has been driven by health technologies and enthusiasts

Primary care:Office Primary care(Office High street)

These concepts can be driven by infrastructure, government and enthusiasts


AUB

Change of outpatient treatment setting:Secondary to primary care???


AUB

Change in philosophy

NHS Operational strategy“Diagnosis & Treatment Centres”

Justin Clark MD (Hons) MRCOG, Birmingham Women’s Hospital


AUB

‘High Street’ Gynaecology??


http://www.gapingvoid.com/tesco88889.jpg

http://www.shakespeareline.com/images/bullring_newst_v.jpg

http://www.shakespeareline.com/images/new_st_v.jpg

AUB

Responding to DoH- ‘Care Closer to home’

The Our health, our care, our say White Paper sets out a vision to provide people with good quality social care and NHS services in the communities where they live. NHS services are half way through a 10 year plan to become more responsive to patient needs….. ..and prevent ill health by the promotion of healthy lifestyles………. Give service users more independence, choice and control.

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4127453


AUB

Responding to DoH- Care Closer to home’

The Our health, our care, our say White Paper sets out a vision to provide people with good quality social care and NHS services in the communities where they live. NHS services are half way through a 10 year plan to become more responsive to patient needs….. ..and prevent ill health by the promotion of healthy lifestyles………. Give service users more independence, choice and control.

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4127453


AUB

Responding to DoH- the Darzi review of the NHS

To set us on the path to the next stage of the transformation of the NHS, the Prime Minister and I have asked Professor Sir Ara Darzi – one of the world’s leading surgeons - to carry out a wide-ranging review of the NHS. This is a once in a generation opportunity to ensure that a properly resourced NHS is clinically led, patient-centred and locally accountable.


AUB







AUB

Uniformly optimsing care

Clear, evidence-based pathwaysStandardised referral criteria⌧Audit compliance and patient outcomes

Requires:⌧‘Specialists within primary care

• ‘GPSIs’ / PCWHF• Nurse practitioners

⌧Lead clinician in secondary care


AUB







AUB

Conclusions

Office-based diagnosis and treatment

Standardised, evidence based care pathways between primary & secondary care

Utilisation of latest medical and surgical health technologies where evidence supports



16th June 2010

Medical management of AUBThe University Of Birmingham




AUB

Up to date guidance

Justin Clark MD (Hons) MRCOG Justin Clark MD (Hons) MRCOG, Birmingham Women’s HospitalCOPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED

Investigations



AUB

Pelvic ultrasound


AUB

What investigations should I arrange in primary care?

Abnormal Uterine BleedingMenorrhagia⌧FBC⌧(Pelvic USS – DEPENDS UPON EXAMINATION FINDINGS)

IMB⌧(Pelvic USS – DEPENDS UPON EXAMINATION FINDINGS)⌧(Genital tract swabs)

PMB/HRT bleed⌧Pelvic USS


Medical Management


Incidence and prevalence of menorrhagia

Affects approximately 880,000 women in EnglandAnnual rate of women with heavy menstrual bleeding

presenting to services

0.67%

2.58%1.94% 1.73%

2.10%

2.96%

4.47%

5.40%

4.64%

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

12 to14

15 to19

20 to24

25 to29

30 to34

35 to39

40 to44

45 to49

50 to51

Age range

Rat

e of

pre

sent

atio

n


AUB

Likely causes of heavy menstrual bleeding

Common Less common Rare

Dysfunctional Uterine Bleeding

Ovular

Anovular (endometrial

hyperplasia)

Gynaecological disease

Endometriosis

Adenomyosis

Diffuse myometrial hypertrophy

Pelvic inflammatory disease

Intrauterine polyps

Gynaecological cancer

Uterus

Ovary (theca and granulosa cell tumours)

Fibroids

Submucous

Intramural

Pregnancy related

Retained products of conception

Endocrine

Thyroid dysfunction

Iatrogenic

Intrauterine contraceptive devices

Exogenous sex hormones

Anticoagulants

Haematological

von Willebrand’s disease

Idiopathic thrombocytopenia


AUB

Common presentations:HEAVY REGULAR PERIODS

Likely diagnosis = ‘dysfunctional uterine bleeding’

TreatmentFirst-line⌧Non-hormonal

• TXA, MFA, (Iron)⌧Hormonal

• COC• Mirena

Second-line• Endometrial Ablation• Hysterectomy

Take home message = Regular menstruation is not associated with significant pathology but treatment is indicated on the impact symptoms have on HRQL


AUB

Common presentations:HEAVY REGULAR PERIODS + FIBROIDS

In the presence of fibroids pharmacological treatments more likely to fail – earlier referral to secondary care for..........

Myomectomy⌧Hysteroscopic⌧Open⌧Radiological

• Uterine Artery Embolisation

Hysterectomy⌧Laparoscopic / Vaginal⌧Open

Take home message = Fibroids are common; symptoms more resistant to standard pharmacological treatments and endometrial ablation


AUB

Common presentations:HEAVY IRREGULAR PERIODS

Likely diagnosis‘Dysfunctional uterine bleeding’Anovulation⌧Endometrial hyperplasia

TreatmentFirst-line⌧Hormonal

• COC• Mirena• Cyclical systemic progestins

Second-line• Endometrial Ablation• Hysterectomy

Take home message = Erratic menstruation requires hormonal or surgical management; further endometrial assessment (biopsy +/- hysteroscopy) is required if >45 years or obese


AUB

Common presentations:HEAVY PERIODS IN TEENAGERS / YOUNG

Likely diagnosis‘Dysfunctional uterine bleeding’⌧ Anovulation

BUT CONSIDER HAEMATOLOGICAL PROBLEM⌧ Von Willebrand’s disease⌧ Platelet disorder

TreatmentFirst-line⌧ Hormonal

• COC +/- TXA/MFA• (Mirena)• (Cyclical systemic progestins)

Second-line• Haematologist / Desmopressin (Octim nasal spray)• Endometrial Ablation• Hysterectomy

Take home message = Consider clotting disorders in young women (bleeding history)


AUB

Heavy Menstrual Bleeding:When is referral to secondary care warranted?

Symptoms refractory to medical treatment

Abnormal clinical examination• Abnormal cervix• Significant tenderness • Pelvic mass not thought to be fibroids• Significant fibroid uterus (palpable abdominally)

Lower threshold for referral if:Risk factors for endometrial hyperplasia

• Irregular periods, obesity, family history, >40 yearsSubstantial impact on health related quality of lifeAssociated iron deficiency anaemia


AUB

Common presentations:INTERMENSTRUAL BLEEDING

Likely diagnosisEndometrium⌧Physiological (hormonal)⌧Dysfunctional uterine bleeding⌧Endometrial instability - ? Progestogen insufficiency⌧Endometrial polyp

Cervix⌧Cervical cancer rare (especially in women with normal smear history)⌧Cervical polyp⌧Lower genital tract infection

Treatment⌧Reassurance⌧COC⌧(Antibiotics)⌧(Cervical cautery)

Take home message = Examine cervix, check smear history, consider triple swabs & arrange a pelvic USS; Distinguish from irregular periods


AUB

Intermenstrual Bleeding:When is referral to secondary care warranted?

Normal examinationPersistent symptoms (Anxiety)

Abnormal clinical examination• Abnormal cervix• Significant tenderness • Pelvic mass not thought to be fibroids


AUB

Common presentations:POSTMENOPAUSAL BLEEDING

Likely diagnosis5-15% = Endometrial cancer / pre-cancer (atypical endometrial hyperplasia)85-95%= Benign pathology

• Atrophic changes to lower genital tract• Endometrial polyps

InvestigationPelvic examinationPelvic ultrasound (endometrial thickness)Outpatient endometrial biopsy +/- outpatient hysteroscopy

ManagementReassurance (50% +)Benign pathology⌧Outpatient hysteroscopy clinic – hysteroscopic polypectomy / myomectomy)⌧Local / systemic oestrogen

Malignant pathology⌧Oncology (hysterectomy/radiotherapy/chemotherapy)

Take home message = Arrange urgent referral via ‘PMB pathway’ for rapid pelvic ultrasoundJustin Clark MD (Hons) MRCOG, Birmingham Women’s HospitalCOPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED

AUB

Post-menopausal Bleeding:When is referral to secondary care warranted?

Mandatory – urgent referral


AUB

Common presentations:HRT RELATED BLEEDING

Likely diagnosis⌧Absorption – compliance / malabsorption⌧Cervical/Endometrial/Ovarian pathology

• Common– Endogenous ovarian activity (i.e ‘perimenopause’)– Endometrial pathology - Hyperplasia, Polyps, ‘Unstable’ atrophic endometrium

Investigation⌧Pelvic examination⌧Pelvic ultrasound (endometrial thickness)⌧Outpatient endometrial biopsy +/- outpatient hysteroscopy

Management⌧Pathology

• Polypectomy; systemic / local progestins (MirenaTM for hyperplasia) ⌧No pathology

• Review need for HRT• Change HRT preparation: Sequential – sequential; Sequential – continuous combined (‘no

bleed’) or vice-versa; ERT +Mirena

Take home message = Exclude gynaecological pathology (pelvic exam + arrange pelvic ultrasound) and review need for and type of HRT


AUB

HRT Bleeding:When is referral to secondary care warranted?

Persistent symptomsDefinition?

Abnormal clinical examination• Abnormal cervix• Significant tenderness • Pelvic mass

Abnormal ultrasound scan Endometrial thickness >4mm

Lower threshold for referral if:Risk factors for endometrial hyperplasia / cancer

• Obesity• Family history• Substantial impact on health related quality of life


Further Information


•Diagnosis and Management of common gynae conditions

•PMB

•HRT & menopause

•Menorrhagia

•Outpatient hysteroscopic surgery -polyps, fibroids

•Mirena

•Essure sterilisation

•Outpatient endometrial ablation


AUB

Conclusions

NICE guidance for HMBTranexamic acid, mefanamic acid, COC and MIRENA

PMB pathways based upon USS and locally organisedUniformity of approach needed⌧Audit of referral rates, treatments, hysterectomy rates,

outcomes, patient satisfaction


Future developments:Abnormal uterine bleeding, fibroids, chronic pelvic pain & endometriosis







16th June 2010

Hysteroscopic surgery and fibroid mangement

The University Of Birmingham




AUB

Routine hysterectomy?


AUB

Examples: Old vs. New ApproachesUterine polyp

INPATIENT

Abnormal Uterine bleeding

Hysteroscopy / D&C under GA

OFFICE


Pelvic Ultrasound

Outpatient hysteroscopic polypectomy


AUB

Examples: Old vs. New ApproachesSubmucous fibroid

INPATIENT


Hysteroscopy / D&C under GA

Reschedule for hysteroscopic resection under GA OR Hysterectomy

OFFICE


Pelvic Ultrasound

Outpatient hysteroscopic resection of fibroid OR scheduling for GA procedure (hysteroscopic resection OR hysterectomy)


AUB

Fibroids: ManagementMedical

⌧TXA, MFA, progestogens, GnRH-a⌧MirenaTM

Surgical⌧Endometrial ablation

• Sound length<12cm

• Regular cavity (no distorting SMFs)⌧Myomectomy

• Hysteroscopic (+/- MirenaTM or endometrial ablation)• Laparoscopic• Open

⌧Hysterectomy

Radiological⌧Uterine Artery Embolisation⌧Other (under evaulation)

• MRI cryoablation; myolysis; USS guided injection; uterine arterial mechanical occlusion)


AUB

Fibroids: ManagementMedical

⌧TXA, MFA, progestogens, GnRH-a⌧MirenaTM

Surgical⌧Endometrial ablation

• Sound length<12cm

• Regular cavity (no distorting SMFs)⌧Myomectomy

• Hysteroscopic (+/- MirenaTM or endometrial ablation)• Laparoscopic• Open

⌧Hysterectomy

Radiological⌧Uterine Artery Embolisation⌧Other (under evaulation)

• MRI cryoablation; myolysis; USS guided injection; uterine arterial mechanical occlusion)


Examples: Old vs. New ApproachesEndometrial Ablation

INPATIENT


Hysteroscopy / D&C / Endometrial Ablation under GA (if suitable)

OFFICE


Pelvic Ultrasound + Outpatient Biopsy

Outpatient hysteroscopy with endometrial ablation


Evidence for Office proceduresOutpatient hysteroscopic sterilisation:


Evidence for Office proceduresOutpatient endometrial ablation:COAT Trial

THE COAT TRIALA RANDOMISED CONTROLLED TRIAL TO COMPARE

THE EFFECTIVENESS OF OUTPATIENTENDOMETRIAL ABLATION TECHNIQUES

(NOVASURETM VERSUS THERMACHOICETM III) IN THE TREATMENT OF MENORRHAGIA


versus


Evidence for Office ProceduresOUTPATIENT POLYP TREATMENT ‘OPT’ TRIAL

RCT comparing outpatient versus inpatient uterine polypectomy

Outcomes:EffectivenessAcceptabilityCosts

Multi-centre trial funded by the DoH Health Technology Assessment Programme (£1.1million)

Collaborating centres welcomeJoint authorship as part of collaborating groupBiannual collaborators meetingsPer patient paymentsOutpatient operative training

Contact:Mr Justin Clarkat Birmingham

Women’s Hospitalfor further

information

Phone:0121 6074712

Email:[email protected]


Conclusions

Office or ‘ambulatory’ hysteroscopic surgery has allowed an efficient, one stop approach to managing intrauterine pathologies and dysfunctional uterine bleeding avoiding hospitaladmission

Fibroids are common and adversely impact upon the effectiveness of standard medical and minimally invasive treatments for AUB. Referral to secondary care is more likely tobe required.


Thank you for your attention

Any Questions?


Abnormal uterine bleeding - Welcome to NHS Networks ... · 16/6/2010 · aModern management of abnormal uterine bleeding (‘AUB’) ... • Significant fibroid uterus (palpable abdominally)

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