Dr Devashana Gupta - PDF document

Dr Devashana Gupta Repromed Auckland 17:30 - 18:00 Fibroids, Endometriosis and DUB Fibroids, Endometriosis and AUB Dr Devashana Gupta 9 th June 2018 3 Abnormal uterine bleeding • PALM - COEIN 4 What is abnormal bleeding • Bleeding outside of the normal menstrual cycle length (21 - 35 days) and outside of the normal parameters i.e. �80mls/cycle! • HMB - no

longer menorrhagia • 1 in 5 women suffer from heavy periods • 50% of women with HMB have pelvic pain • 77% of women with heavy periods have depression and moodiness • 63% of women report missing social activities due to their heavy periods • 84% of women with heavy periods report having less energy or no energy at all 5 How heavy is heavy? 6 Endometrial/endoc

ervical polyps - AUB - P • Epithelial proliferations, consisting of vascular, glandular, fibromuscular and connective tissue cells • Often asymptomatic but a/w HMB • Polyps may interfere with fertility but controversial • CR 2015: OR 2.45 for clinical pregnancy with removal of endometrial polyp prior to IUI treatment • Therefore, historically recommend

removal of pol�yps 2 - 3cm if undergoing IUI/IVF 7 Adenomyosis - AUB - A • Endometrial tissue within muscle of uterus, 5 - 60% prevalence • Used to be called endometriosis interna, no longer under one disease entity. Unknown etiology. • Possible abnormal migration of endometrium into myometrial layer • Causes uterine enlargement, heavy menstruation an

d dysmenorrhea, dyspareunia. 33% asymptomatic. • Diagnosis: histology at hysterectomy. �10*6 endometrial glands in muscle. • USS - venetian blind effect, globular and enlarged uterus • MRI can be useful pre - operatively • Rx: NSAIDs, hormonal treatment, curative = hysterectomy. 8 Fibroids/Leiomyomas – AUB - L • Benign fibromuscular tumors of the

myometrium • Common and maybe asymptomatic in a large portion of the population • Symptoms: HMB, pressure effect, bladder/bowel symptoms • Diagnosis: USS. MRI if further assessment required for diagnosis of malignancy. • Leiomyosarcoma 0.5 - 1%. 5 yr survival • Treatment - hormonal, UAE, MRgFUS, surgery - uterine sparing plus non sparing 9 Fibroid classi

fication FIGO 10 Uterine fibroids and fertility management • ACCEPT guidelines 2011 • Effect on fertility (Level 3 evidence) • SS don’t appear to have an effect • IM may be associated with reduced fertility and increased miscarriages • SM associated with reduced fertility and increased miscarriages • Management of fibroids in infertile women • Hysterosco

pic resection likely to improve fertility outcomes (level2) • IM insufficient evidence to determine benefit (Level 2) • Fibroid size, number and location may impact on the usefulness of myomectomy • Indications for myomectomy • Infertile woman with SM fibroid (level 2) • Infertile woman with symptomatic fibroids (level 4) • Previous multiple failed ART cycles

with IM fibroids (level 4) 11 Myosure tissue removal system 12 Malignancy/hyperplasia - AUB - M • Endometrial hyperplasia • Previous WHO94 classification: 4 groups - atypical hyperplasia (simple and complex) and non - atypical hyperplasia (simple and complex). Risk of malignancy 8 - 29% • Newer WHO2014 classification: 2 groups - Benign hyperplasia (5% risk of pro

gression to malignancy over 20 yrs) and atypical hyperplasia/endometrial intraepithelial neoplasia (EIN) • Endometrial adenocarcinoma • Risk factors: unopposed estrogen, increased BMI, tamoxifen, nulliparity • Cervical cancer 13 COEIN • AUB - C: Coagulopathy - consider if HMB since menarche especially with family history. 13%in studies, largely VWD. • AUB - O

: Ovulatory dysfunction - anovulatory cycles tend to be irregular. • AUB - E: endometrial issue e.g. infection, inflammation • AUB - I: iatrogenic. E.g. hormonal medications, Mirena, warfarin • AUB - N: not yet classified e.g. AVM 14 Medical management of AUB • Any management needs to focus on improving QOL rather than just reducing the menstrual blood loss •

Ascertain preference and comorbidities, exercise and BMI • Do nothing approach - doesn’t really work! • Treat the cause e.g. polyp • Non - hormonal - Cyclokapron, NSAIDs* (20 - 46% reduction) • Hormonal - cyclical progesterone, OCP*, Depo Provera, Mirena • Mirena IUS - 3 - 6/12 to settle in. 97% reduction in HMB. Suitable for SM fibroids denomyosis and endom

etriosis. Pharmac subsidized if anemic. ECLIPSE trial. • Less used - GnRHa, Danazol • Ulipristal for fibroids - SPRM. Recently taken off the market - 4 liver failure cases 15 Surgical management of AUB • Surgical removal of cause - fibroids, polyps • Endometrial ablation • Hysterectomy with conservation of ovaries, consider removal of fallopian tubes • Uter

ine preservation surgery - UAE, MRgFUS • *CR 2016 - Mirena IUS, endometrial surgery and hysterectomy have highest reduction in HMB rates • CR 2013 - Endometrial surgery compared to hysterectomy. Short term ablation is more cost effective but this narrows with the re - operation rates are taken into account. Hysterectomy tends to be a longer operation, higher compli

cation rate and longer recovery. 16 Novosure • RF device for management of HMB • Simple procedure that can be performed as a day stay and even outpatient. Newer devices have a 6mm diameter • Safety checks in place that ensure cavity seal • However, complications can still arise and include bowel injury • Pre and post - op NSAIDs helpful • Cramping and bro

wnish discharge • Long term contraception required as high risk pregnancy 17 Endometriosis • Common, benign and chronic disease. No racial predisposition • 6 - 10% reproductive age women • Commonest cause of chronic pelvic pain - 35 - 50% • Cause of infertility in 10 - 15% of couples, maybe more upto 35 - 80% in women undergoing laparoscopy for pelvic pain •

Adolescence and infertile women undergoing laparoscopy for dysmenorrhoea/infertility - 50% • Financial burden $350million/year (Aus.) - diminished QOL, missed productivity, medical and surgical Rx and chronic nature 18 Endometriosis epidemiology & pathogenesis • Protective: • Increasing parity • OCP: conflicting evidence: risk decreased in current users • Sm

oking - anti - estrogenic effect • Other risk factors: immune diseases such as RA, SLE • Lifestyle and dietary factors - controversial • Environmental exposures - E2 well established, dioxin and heavy metals such as cadmium also been implicated 19 Pathogenesis • Proposed mechanisms • Retrograde menstruation/implantation theory* • Coelomic metaplasia theory

• Lymphatic or vascular spread theory/embolic • Direct transplantation theory • Altered immunity theory • Mullerian rest theory • Pluripotent stem cell theory 20 Symptoms and signs • Asymptomatic • 4 D’s: dysmenorrhoea (90%), dyspareunia (comm deep - 75%), dyschezia and dysuria • Cyclical pelvic pain • Chronic pelvic pain (70%) • Infertility (

55%) • Deceased QOL scores • Other GI symptoms - PR bleeding, cyclical bloating, alternating bowels • Other urological symptoms - haematuria, urinary frequency and urgency 21 What causes pain & infertility? • What causes pain: • Micro - haemorrhages in implants with resultant inflammation • Anatomy is distorted • Nerve involvement: lesions innervated, pred

ilection for nerve fibres • Nociceptive mediators: inflammatory cells and mediators • Chronic pain syndrome: central sensitisation thru denervation and re - innervation (Stratton and Berkley, 2011) • Anatomical distortion in stages 3 and 4 - impaired tubes/ovarian relationship, endometrioma • Oocytes - reduced reserve, cytokines elevated • Fertilisation - abnor

mal peritoneal macrophages • Subclinical pelvic inflammation - altered peritoneal fluid • Embryo quality - poor due to egg quality, toxic intraperitoneal, intratubal and endometrial environment • Implantation receptivity - endometrial autoabs, abnormal cell adhesion molecules, adenomyosis 22 Tertiary level care for Severe Endometriosis Clearly defining and expla

ining the extent of the disease Providing appropriate counselling and psychological support Providing a nurse specialist who will interface between patient and specialist team Individualising care based on the patient’s specific symptom complex and preferences Consideration of the patient’s fertility needs Assessing quality of life before, and at intervals after, t

reatment Providing high quality treatment and care to relieve symptoms of endometriosis 23 Tertiary Service Providing complex laparoscopic surgical excision of all endometriosis Retaining pelvic structures unless there is an objective reason to remove them Maintaining a detailed surgical database to include detail of surgery and any complications Recording relevant c

linical domains and quality of life Working with pain management specialists Keeping the use of open surgery to the minimum 24 Diagnosis • Average time to diagnosis of 8 years! • Believe that cyclical pain is normal • Differing pain thresholds making seeking medical help difficult • Other common causes of pain: PID and IBS sharing symptoms • Lack of non - invas

ive diagnostic methods • Differing macroscopic forms: dependent on surgeon’s experience, location and type of lesion • History and examination contributes majorly • Tertiary endometriosis USS • MRI • Laparoscopy is however the only diagnostic test that is sufficiently accurate • 94% sensitivity • 74% specificity • Non - invasive diagnostic tests: blood

, endometrial, urine and combined 25 Ultrasound pelvis • Endometrioma detection sensitivity 64 - 90% and specificity 90 - 100% • Doesn’t diagnose peritoneal endometriosis • Useful for assessment of ovaries for endometriomas • Bladder nodules can also be detected • Assessment of tenderness, mobility versus fixation of organs • Sliding sign - obliteratio

n of POD if rectosigmoid doesn’t slide freely against upper vagina and uterus 26 Pre - operative assessment - MRI MRI (magnetic resonance imaging) predicts 95% of deep endometriosis pre - operatively and assists in the planning of surgery. MRI needs to be reported by a radiologist with expertise in endometriosis. 27 Management overview • Individualise treatment

based on symptoms • Depends on age, extent of disease, symptoms and future fertility expectations • Medical • Symptomatic management: NSAIDs, Ponstan, acupuncture, mindfulness • Hormonal: menstrual suppression (not appropriate for infertility). Cyclical or continuous. OCP/Progesterone alone. GnRH, Danazol • Failed medical treatment warrants surgery • Surgic

al • Excision versus ablation • Staged surgery • Pelvic clearance 28 29 Surgical management of endometriosis • Post medical treatment failure, patient request, stage 3/4 endometriosis, infertility • Proper pre - operative assessment • Conservative surgery with preservation of uterus and as much ovarian tissue if fertility is a concern • Realistic expectati

ons of patients - incurable condition and likely will require repeat surgery if symptoms return - 30% after 5 years • Laparoscopy preferred technique • Aims: treat all visible disease, conserve fertility, restore anatomy, prevent or delay recurrence 30 Impact on fertility and pregnancy • Endometriosis in a large cohort study over 8000 women was associated with

(SS): • Miscarriage OR 2.44 • Early pregnancy loss OR 2.62 • Placenta praevia aOR 2.24, PPH 1.30, LSCS 1.40 31 References • NICE guidelines • RANZCOG guidelines • Novosure / Myosure website • S Lyons. Endometriosis: essentials for general practice. • Jean Hailes Foundation: Endometriosis • WES Consensus • RCOG 2016 - Endometrial hyperplasia 32 Tha