Heavy Menstrual Bleeding the nice guideline

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Heavy Menstrual Bleeding the nice guideline

• Kathryn Boothroyd
• GP ST1
• 2007

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(No Transcript)
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Contents

• Definition
• Epidemiology
• Pathophysiology
• History examination
• Investigations
• Indications for referral
• Treatments medical and surgical

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What isnt covered

• Conditions where HMB is not the main presenting
  menstrual symptom e.g. Endometriosis.
• Issues relating to anaesthetics in surgery.
• Issues relating to fertility are only mentioned
  as they relate to treatment for HMB not as a
  separate issue.
• Women with HMB receiving exogenous steroids, such
  as hormone replacement therapy (HRT).
• Other gynaecological bleeding problems e.g. PCB/
  PMB.

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Definition

• 60ml to 80ml blood loss per menstruation
• excessive menstrual blood loss which interferes
  with the womans physical, emotional, social and
  material quality of life, and which can occur
  alone or in combination with other symptoms. Any
  interventions should aim to improve quality of
  life measures.

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Epidemiology 1

• Evidence statements on prevalence of HMB
• Studies show that between 4 and 51.6 of women
  experience HMB. However, these results are based
  on figures from a number of different countries
  and clinical settings and the effects of these
  factors on the results have to be considered.
• Sociocultural factors also influence an
  individual womans response to menstrual blood
  loss, and this must be taken into account during
  consultation.

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Pathophysiology 1

• Pathology may be either cause or consequence of
  HMB, or be associated, but without a causal
  relationship.
• Investigations should be directed towards
  pathology that is correctable and the treatment
  of which results in health gains or the
  prevention of illness.

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pathophysiology 2

• HMB is associated with
• Uterine fibroids
• Race
• Age
• Von Willebrand Disease
• Endometriosis
• HMB is not associated with
• Uterine polyps
• Thyroid disease
• Genetic inheritance
• HMB may be associated with
• Parity
• Lifestyle

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Pathophysiology 3

• The majority of women with HMB have no
  histological abnormality that can be implicated
  in causing HMB. Uterine fibroids (approximately
  30 of women) and polyps (approximately 10 of
  women) are the most common form of pathology
  found.
• The RCOG guidelines on HMB estimated that in
  women aged between 35 and 54 years, 8 of every 10
  000 women who presented with HMB in primary care
  would have endometrial carcinoma.

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History taking for HMB 1

• Should aim to meet these objectives
• to define the nature of bleeding
• to identify potential pathology
• to identify womens ideas, concerns,
  expectations and needs.

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History taking for HMB 2

• Should include the following
• Age
• Changes in bleeding pattern, IMB, PCB
• Dyspareunia/ pelvic pain/ pressure effects
• Smear history
• Family history of gynaecological pathology
• Future fertility and contraception plans
• Previous treatments and their effectiveness
• The impact of the HMB on the womans quality of
  life
• Co-morbidities which may influence treatment.

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Examination in hmb

• Should include an abdominal examination,
  speculum examination, bimanual palpation.
• Should be carried out before all
• LNG-IUS fittings
• investigations for structural abnormalities
• investigations for histological abnormalities.

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Investigations 1

• Laboratory tests
• FBC on all women with HMB.
• Testing for coagulation disorders (for example,
  von Willebrand disease) should be considered in
  women who have had HMB since menarche and have
  personal or family history suggesting a
  coagulation disorder.
• A serum ferritin test should not routinely be
  carried out on women with HMB.
• Female hormone testing should not be carried out
  on women with HMB.
• Thyroid testing should only be carried out when
  other signs and symptoms of thyroid disease are
  present.

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Investigations 2

• Indications for taking an endometrial biopsy to
• exclude endometrial carcinoma or atypical
• hyperplasia as a cause of HMB
• persistent intermenstrual bleeding
• women aged 45 and over
• treatment failure or ineffective treatment

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Investigations 3

• Ultrasound is the first-line diagnostic tool for
  identifying structural abnormalities. TV US
  should be requested in the following
  circumstances
• the uterus is palpable abdominally
• vaginal examination reveals a pelvic mass of
  uncertain origin
• pharmaceutical treatment fails.
• Hysteroscopy should be used as a diagnostic tool
  only when ultrasound results are inconclusive,
  for example, to determine the exact location of a
  fibroid or the exact nature of the abnormality.

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Investigations 4

• If imaging shows the presence of uterine
  fibroids then appropriate treatment should be
  planned based on size, number and location of the
  fibroids.
• Saline infusion sonography should not be used as
  a first-line diagnostic tool.
• Magnetic resonance imaging (MRI) should not be
  used as a first-line diagnostic tool.
• Dilatation and curettage alone should not be
  used as a diagnostic tool.
• Where dilatation is required for
  non-hysteroscopic ablative procedures,
  hysteroscopy should be used immediately prior to
  the procedure to ensure correct placement of the
  device.

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Indications for referral

• Women with these conditions should be offered
  immediate referral to a specialist
• fibroids that are palpable abdominally
• intra-cavity fibroids
• women whose uterine length as measured at
  ultrasound or hysteroscopy is greater than 12 cm
  
• Women who are considering surgical treatment
  should be referred routinely to a specialist.
  The potential treatment options should be
  explained to the woman before she is referred.

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Non-surgical treatments

• 1. levonorgestrel-releasing intrauterine system
  (LNG-IUS) provided long-term (at least 12 months)
  use is anticipated
• 2. tranexamic acid or nonsteroidal
  anti-inflammatory drugs (NSAIDs) or combined oral
  contraceptives (COCs)
• 3. norethisterone (15 mg) daily from days 5 to 26
  of the menstrual cycle, or injected long-acting
  progestogens.

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Non-hysterectomy Surgical treatments 1

• Endometrial ablation is suitable when
• Bleeding is having a severe impact on a womans
  quality of life, and she does not want to
  conceive in the future.
• The woman has a normal uterus and/or small
  uterine fibroids (less than 3 cm in diameter).
• Facts about endometrial ablation
• It may be offered as an initial treatment for HMB
• Women must be advised to avoid subsequent
  pregnancy and on the need to use effective
  contraception, if required, after endometrial
  ablation.
• In women with HMB alone, with uterus no bigger
  than a 10 week pregnancy, endometrial ablation
  should be considered preferable to hysterectomy.
• All women considering endometrial ablation should
  have access to a second-generation ablation
  technique.

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Non-hysterectomy Surgical treatments 2

• Second-generation ablation techniques should be
  used where no structural or histological
  abnormality is present. The second-generation
  techniques recommended for consideration are as
  follows
• impedance-controlled bipolar radiofrequency
  ablation
• fluid-filled thermal balloon endometrial ablation
  (TBEA)
• microwave endometrial ablation (MEA)
• free fluid thermal endometrial ablation

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Further interventions for uterine fibroids
associated with hmb

• Consider, discuss and document the discussion
  of
• Uterine Artery Embolisation
• Myomectomy
• Hysterectomy
• Women should be informed that UAE or myomectomy
  will potentially allow them to retain their
  fertility.

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Hysterectomy 1

• Hysterectomy should not be used as a first-line
  treatment solely for HMB. Consider only when
• 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.
• The following must be discussed
• Increased risk of complications in presence of
  fibroids
• Possible loss of ovarian function and need for
  HRT

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Hysterectomy 2

• 1st line route vaginal hysterectomy
• 2nd line route abdominal hysterectomy
• (discuss both total and subtotal procedures)
• Under circumstances such as morbid obesity or
  the need for oophorectomy during vaginal
  hysterectomy, the laparoscopic approach should be
  considered, and appropriate expertise sought.

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Oophorectomy at the time of hysterectomy 1

• Removal of healthy ovaries at the time of
  hysterectomy should not be undertaken.
• Removal of ovaries should only be undertaken with
  the express wish and consent of the woman.
• Women with a significant family history of breast
  or ovarian cancer should be referred for genetic
  counselling prior to a decision about
  oophorectomy.

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Oophorectomy at the time of hysterectomy 2

• In women under 45 considering hysterectomy for
  HMB with other symptoms that may be related to
  ovarian dysfunction (for example, premenstrual
  syndrome), a trial of pharmaceutical ovarian
  suppression for at least 3 months should be used
  as a guide to the need for oophorectomy.
• If removal of ovaries is being considered, the
  impact of this on the womans wellbeing and, for
  example, the possible need for hormone
  replacement therapy (HRT) should be discussed.
• Women considering bilateral oophorectomy should
  be informed about the impact of this treatment on
  the risk of ovarian and breast cancer.

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Reference

• National Collaborating Centre for Womens and
  Childrens Health, Clinical Guideline, January
  2007, funded to produce guidelines for the NHS by
  NICE.