Heavy menstrual bleeding NICE Guidelines, Aboubakr Elnashar

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Heavy menstrual bleeding NICE Guidelines Prof Aboubakr Elnashar Benha university, Egypt Email: [email protected]
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Transcript of Heavy menstrual bleeding NICE Guidelines, Aboubakr Elnashar

  • Heavy menstrual bleeding NICE Guidelines Prof Aboubakr Elnashar Benha university, Egypt Email: [email protected]
  • HMB Excessive MBL which interferes with the womans physical, emotional, social & material quality of life, and which can occur alone or in combination with other symptoms. Any interventions should aim to improve quality of life.
  • History 1. Nature of the bleeding 2. Related symptoms that might suggest structural or histological abnormality 3. Impact on quality of life 4. Other factors that may determine treatment options (such as presence of comorbidity).
  • If the history suggests HMB without structural or histological abnormality: pharmaceutical treatment can be started without carrying out a physical examination or other investigations, unless the treatment chosen is LNG- IUS. If the history suggests HMB with structural or histological abnormality (intermenstrual or postcoital bleeding, pelvic pain and/or pressure symptoms): Physical examination and/or other investigations (US) should be performed.
  • Measuring MBL either directly (alkaline haematin) or indirectly (Pictorial blood loss assessment chart) is not routinely recommended. {Whether MBL is a problem should be determined not by MBL but by the woman herself}.
  • Pictorial blood loss chart: (Higham,1990) Days of the bleeding Score 1 2 3 4 5 6 7 8 Towel 1 ponit 5 ponits 10 points Clots 1p clot 1 point 5p clot 5 points Flooding 5 points Score >100 = Menorrrhagia
  • Examination Indications: Before 1. LNG-IUS fittings 2. Investigations for structural abnormalities 3. Investigations for histological abnormalities.
  • Laboratory tests A full blood count test should be carried out Testing for coagulation disorders (von Willebrands disease) should be considered 1. HMB since menarche 2. Personal or family history suggesting a coagulation disorder. A serum ferritin test should not routinely be carried out Hormone testing should not be carried out Thyroid testing should be carried out only when other S&S of thyroid disease are present.
  • Structural and histological investigations Biopsy {exclude endometrial cancer or atypical hyperplasia}. Indications: 1. Persistent intermenstrual bleeding 2. Age 45 & over 3. Failure or ineffective treatment. Advantages: 1. An outpatient procedure 2. No general anesthesia. 3. Complications are rare An adequate & acceptable screening procedure
  • Types Reusable: Vabra aspirator (95%) Sharman curette, Novak curette (90%), Kevorkian Randall Disposable Pipelle curette (90%) Accurette Z-sampler (83%), Mi-Mark Helix (93%), Endopap (70%), Perma curette (73%) Endorette Explora (70%) Karman (95%) Ti-Utrap Gynocheck
  • Pipelle: Is tolerated better than most other forms Samples 4.2% of the endometrial surface Detection rate of endometrial cancer: 90% Vabra aspiration: Only samples 42% of the endometrial surface Less tolerated than other forms Compared with curretage, complications are less & the detection rate of endometrial abnormalitis are higher (Grimes,1982)
  • Novak curette Kevorkian curette
  • Endocurette Pipelle
  • US is the first-line diagnostic tool for identifying structural abnormalities. US should be undertaken when: 1. The uterus is palpable abdominally. 2. Vaginal exam: a pelvic mass of uncertain origin. 3. Pharmaceutical treatment fails.
  • Hysteroscopy should be used as a diagnostic tool only when US results are inconclusive (for example, to determine the exact location of a fibroid or the exact nature of the abnormality). Saline infusion sonography should not be used as a first-line diagnostic tool. MRI should not be used as a first-line diagnostic tool. Dilatation & curettage alone should not be used as a diagnostic tool.
  • Pharmaceutical treatments Indications: 1. No structural or histological abnormality 2. Fibroids < 3 cm no distortion of the uterine cavity. Determine she wish to conceive or not
  • Treatments should be considered in the following order: a) LNG-IUS provided long-term (at least 12 ms) use is anticipated b) Tranexamic acid (3-6 gm/d for the first 3 days of the cycle) or NSAIDs (Mefenamic acid 500 mg tds during menses). or COCs c) Norethisterone (15 mg daily, D5-26 of the cycle) or injected long-acting progestogens
  • Mirena
  • When HMB coexists with dysmenorrhoea, NSAIDs should be preferred to tranexamic acid. Ongoing use of NSAIDs and/or tranexamic acid is recommended for as long as it is found to be beneficial by the woman. Use of NSAIDs and/or tranexamic acid should be stopped if it does not improve symptoms within 3 menstrual cycles. When a first pharmaceutical treatment has proved ineffective, a second pharmaceutical treatment can be considered rather than immediate referral to surgery.
  • GnRHa: could be considered 1. Prior to surgery or 2. When all other treatment options for fibroids, including surgery or UAE, are contraindicated. If this treatment is to be used for >6 ms or if adverse effects are experienced then HRTadd- back therapy is recommended. Danazol should not be used routinely (200 mg/d) Oral progestogens given during the luteal phase only should not be used. Etamsylate should not be used.
  • Side effects
  • Non-hysterectomy surgery Endometrial ablation Indicated: Bleeding having a severe impact on a womans quality of life, and she does not want to conceive in the future. Types: Balloon thermal endometrial ablation Microwave endometrial ablation, Free fluid endometrial ablation Impedance-controlled bipolar radiofrequency ablation Endometrial cryotherapy is not covered by this guideline.
  • Endometrial ablation Indications: 1. Initial treatment after full discussion with the woman of the risks & benefits and of other treatment options. 2. Small uterine fibroids (3cm): With significant symptoms (dysmenorrhoea or pressure symptoms): surgery or UAE as first-line treatment. UAE, myomectomy or hysterectomy: bleeding having a severe impact on quality of life. Women should be informed that UAE or myomectomy may potentially allow them to retain their fertility. Myomectomy: Woman wants to retain their uterus.
  • UAE: Woman wants to retain their uterus and/or avoid surgery. Prior to scheduling of UAE or myomectomy, the uterus & fibroid(s) should be assessed by US. If further information about fibroid position, size, number and vascularity is required, MRI should be considered. Pretreatment before hysterectomy and myomectomy with GnRha for 3 to 4 ms should be considered where uterine fibroids are causing an enlarged or distorted uterus. If a woman is being treated with GnRha & UAE is then planned, GnRHa should be stopped as soon as UAE has been scheduled.
  • Hysterectomy Should not be used as a first-line treatment solely for HMB. Indications: 1. Other treatment options have failed, contraindicated or declined by the woman 2. There is a wish for amenorrhoea 3. Woman (who has been fully informed) requests it 4. Woman no longer wishes to retain her uterus and fertility.
  • Discussion of the implication of hysterectomy: 1. Sexual feelings, fertility impact, bladder function, need for further treatment, treatment complications, the womans expectations, alternative surgery and psychological impact. 2. Increased risk of serious complications (such as intraoperative haemorrhage or damage to other abdominal organs) 3. Risk of possible loss of ovarian function and its consequences, even if their ovaries are retained during hysterectomy.
  • Route of hysterectomy. The following factors need to be taken into account: 1. Other gynaecological conditions or disease 2. uterine size 3. presence and size of uterine fibroids 4. mobility and descent of the uterus 5. size and shape of the vagina 6. history of previous surgery. Taking into account the need for individual assessment, the route of hysterectomy should be considered in the following order: first line vaginal; second line abdominal.
  • Morbid obesity or the need for oophorectomy during vaginal hysterectomy: laparoscopic approach should be considered, and appropriate expertise sought. When abdominal hysterectomy is decided upon then both the total method and subtotal method should be discussed with the woman.
  • 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.
  • 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 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.
  • Investigate routine use of indirect measurements of MBL in primary and secondary care Evidence shows that direct measurement of MBL is accurate but complex to undertake in clinical practice, and that subjective assessment of MBL is inaccurate but easy to undertake in clinical practice. An alternative is the use of indirect measures of MBL, such as the Pictorial blood loss assessment chart. However, evidence on the use of indirect measures is contradictory & no data are available to show whether they could be used in routine practice. If indirect measures are shown to work then they could be introduced as a simple technique for assessing MBL, and from this the management of HMB could be improved.
  • What are the long-term recurrence rates of fibroids after UAE or myomectomy? Both UAE and myomectomy are undertaken to reduce symptoms associated with uterine fibroids by directly removing the fibroid(s) or reducing their size. Data exist on short- and medium-term recurrence of fibroids, but no data are available on long-term recurrence.
  • What are the effects of hysterectomy and oophorectomy on the occurrence of cancer? Epidemiological studies are required to investigate the impact of hysterectomy and oophorectomy on cancer. The results of this research will have fundamental implications on the use of these treatments.