abnormal uterine bleeding in fertile age minimally
TRANSCRIPT
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AbnormaluterinebleedinginfertileageMinimallyinvasivesurgicalsolution
ProfessorGrigorisF.Grimbizis
Head,1stDeptObstet&Gynecol,AristotleUniversityofThessaloniki
ESGEChairElect
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DeclarationofInterests
➢ None(commercial)
➢ ESGEChairElect
➢ ESHREPastMemberoftheExecutiveCommittee
➢ HellenicSocietyforEndoscopicSurgeryVicePresident
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AbnormalUterineBleeding:Definition/Comments
AbnormalUterineBleedingisdefinedasbleedingfromtheuterinecorpusthatisabnormalinvolume,regularityand/ortimingwithanestimatedbloodloss>80mlperperiod➢ Theterm“dysfunctional”uterinebleedingisabandoned➢ Life-timeprevalence~30%➢ Substantialimpactonwomen’sphysical,emotional,socialand
materialqualityoflife
➢ Associatedwithlossofproductivity,andmajorhealthcarecosts
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Frequency(days)
Infrequent(>38days)
Normal(24-38days)
Frequent(<24days)
Regularity(12movariaton)
Absent(-)
Regular(±2-20days)
Irregular(>20days)
Duration(days)
Shortened(<4,5days)
Normal(4,5-8,0days)
Prolonged(>8days)
Volume(monthly/ml)
Light(<5ml)
Normal(5-80ml)
Heavy(>80ml)
Menstrualparameters
Munro,RevEndocrMetabDisorders,13:223-234,2012
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AbnormalUterineBleeding(AUB)• Acute• Intermittent• Chronic
FIGOClassificationofAUB
PALM(Structural)
Polyps
Adenomyosis
Leiomyomas
Malignancy
COEINCoa
gulopathy
Ovulatory
Endometrial
Iatrogenic
NotClassified
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Whatisconsideredasminimallyinvasivesurgery?
Hysteroscopy
Diagnostic
Operative
Laparoscopy
Diagnostic
Operative
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WhereistheplaceofminimallyinvasivesurgeryinthemanagementofAUB?
ConfirmationofAUB(basedonsymptoms)DiagnosticWork-up(etiological
investigation)
Treatment(basedondiagnosis)
ManagementofAUBpatient
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Ishysteroscopicinvestigationnecessaryincasesofpolyps?Whyhysteroscopy?
• Rationaleforhysteroscopicpolypectomy• Histology(malignancy,premalignant)
• BlindD&C,evenunderultrasoundcontrol,nolongerrecommended(success<50%/traumaticforendometrium)
• “Seeandtreat”• Bleedingcontrol(improvement75-100%ofcases)
Isthereaplaceforexpectantmanagement?
• Whenpolypssizeis<1cm• Whenthediagnosisofpolyp
shouldnotbeconsideredasdefinite• polypoidprotrusionsoftheendometrium/hyperechoicendometrialareas
• Re-evaluationofsymptomsandimagingfindingsafter3menstruations• “naturalcurettage”
FIGOP(ALM)-Endometrialpolyps
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HysteroscopicinvestigationincasesofAUB&infertility
Non-diagnosticfindings Septum&polyps
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Atypicalpolypoidadenomyoma Endometrialadenocarcinoma
AtypicalpolypoidadenomyomaEndometrial
adenocarcinomaHysteroscopicfindings
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Atypicalpolypoidadenomyomas
HysteroscopicviewNocleardifferencefromnon-
adenomyoticpolyps!!!
UltrasoundimageNodifferencefromendometrial
polyps!!!
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0
3
6
9
12
EndometrialHyperplasia EndometrialAdenocarcinoma
8,8%(12/136cases)
Heatley,Histopathology,48:605-626,2006
8,8%(12/136cases)
6,6%withinthepolyp2,2%intheadjacentendometrium
Atypicalpolypoidadenomyomas:Riskofendometrialcarcinoma
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➢ SamplingofendometrialtissueisanimportantapproachinfertileagewomenwithAUB
➢ AlthoughendometrialmalignancyisfoundrarelyamongfertileagewomenwithAUB,itmustbeexcludedpriortoanysurgicalintervention
➢ AmbulatoryhysteroscopycandiagnosediffuseorfocalendometrialhyperplasiaormalignancyandaidblindordirectedEndometrialBiopsy
Copperetal,2015
FIGOPAL(M)-Malignancy/Premalignantconditions
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Distributionofageinwomenwithendometrialcomplexhyperplasiaorcancer
Agecut-offforbiopsywasremoved
itisnolongerrelevant
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Shoulddiagnosisbebasedonlyinhysteroscopicfindingswithouthistologicalconfirmation?
• The pre-test probability of endometrial cancer was 3.9% (95% CI 3.7%-4.2%)
• A positive hysteroscopy result increased the probability of cancer to 71.8% (95% CI 67%-76.6%)
• A negative hysteroscopy result decreased the probability of cancer to 0.6% (95% CI 0.5%-0.8%)
• The overall accuracy for the diagnosis of endometrial disease was moderate compared to that of cancer
Accuracy of hysteroscopy in the diagnosis of endometrial cancer and hyperplasia: a systematic review
Conclusion: hysteroscopic investigation should always be completed with guided histological examination
Clarketal,JAMA,288:1610,2002
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Isthereaplaceforminimally
invasive(hysteroscopic)investigation?
COEIN
Coagulopathy
Ovulatory
Endometrial
Iatrogenic
NotClassified
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Focallydisorderedproliferativeendometrium
Hysteroscopic“currettage”Removalofthefunctional
endometriallayer
41yearsold-Heavymenstruation/spotting-Noultrasoundfindings
DiagnostichysteroscopyAdhesion(non-significant)/
Normalappearingendometrium/protrusion?
FIGOCO(E)IN–Endometrial
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FIGOCOEI(N)–
Hysteroscopicimagessuggestiveofadenomyosis
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AUBPatient:diagnosticwork-up
Imaging
Confirmationofdiagnosis
Leiomyomas
Adenomyosis
Iatrogenic(Niches)
Findingsneededhistology
Polyps
Suspectedendometrialpathology
Nofindings
Exclusionofendometrialpathology
Isthereaplaceforminimally
invasiveinvestigation?
Hysteroscopy
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Persistent• intermenstrualbleeding
• Irregularuterinebleeding
• infrequentheavybleeding
Heavymenstrualbleedingnotrespondingtomedication
Tamoxifenintake
Obese(BMI>30) PCOS
ConsiderhysteroscopicguidedendometrialbiopsyNICE2018
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MinimallyinvasivesurgicalsolutioninthetreatmentofAUB?
“Causative”
treatmentSymptom
atictreatment
Minimallyinvasive/Invasive
Medical/Non-surgical
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FIGOP(ALM)-Polyps(atypicalpolypoidadenomyomas)
InitialStepResectionofpolypin
healthybordersPathologyofthelesion!!!
Resectionofendometriumaroundthelesion
Resectionofmyometriumunderthelesion
Multiplerandombiopsiesoftheendometrium
DiSpiezioSardoetal,FertilSteril,89:456,2008
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Recurren
cera
tes
0
10
20
30
40
TypicalPolypoidAdenomyomas
RecurrenceratesaftertreatmentofpolypoidadenomyomasPooledresultsofhysteroscopicandD&Ctreatment
4/21reportedcases
37,5%
Mikos&Grimbizis,unpublisheddata,2017
54/144reportedcases
19%
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Recurren
cera
tes
0
12,5
25
37,5
50
HysteroscopicPolypectomy D&C
RecurrenceratesofatypicalpolypoidadenomyomasHysteroscopicvsD&Ctreatment
6/28reportedcases
41,4%
48/116reportedcases
23,7%
Mikos&Grimbizis,unpublisheddata,2014
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FIGO(P)A(LM)-Adenomyosis
Non-surgicalmedicaland/orinterventional• Hormonaltreatment:GnRH-a/LNG-IUS• Uterinearteryembolization• MagneticResonanceguidedFocused
UltrasoundSurgery(MRgFUS)
Uterussparingminimallyinvasivetreatment• Adenomyomectomy(laparoscopicor
hysteroscopic)• Thermalablationofmyometrium• Endometrialablation
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FIGO(P)A(LM)-Adenomyosis
Diffuseadenomyosis• Medicaltreatment(LNG-IUD)
Focaladenomyosis• Minimallyinvasivesurgicaltreatment(adenomyomectomy)
Polypoidadenomyosis• Minimallyinvasivesurgicaltreatment(hysteroscopic)
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Sub-serouslayer5to10mmcouldbeusuallypreservedduringlesionexcisionsinceitisrarelyaffectedbythedisease
FIGO(P)A(LM)-AdenomyosisConservativeexcisionalsurgery
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Reduc^onofPain Reduc^onofBleeding
N=83
Grimbizisetal,FertilSteril,101:472-487,2014
Adenomyomectomy:post-operativeresultsReductionofpainandbleeding
N=385
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FIGO(PA)L(M)-Leiomyomas
Classical FIGO
Submucosal:myomasthatdistorttheuterinecavity
SubmucosalType0 100%intra-cavitary Type0
SubmucosalTypeI >50%intra-cavitary Type1
SubmucosalTypeII <50%intra-cavitary Type2
Intramural:myomaswithinthemyometriumthatdonotdistorttheuterinecavity
Intramural Incontactwiththeendometrium(JZmyomas) Type3
Intramural 100%intramural Type4
Intramural Intramuralbut<50%subserosal Type5
Subserosal:myomaswith>50%extensionoutoftheserosalsurface
Subserosal Subserosalbut<50%intramural Type6
Subserosal Pedunculated Type7
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FIGO(PA)L(M)-Leiomyomas
AbnormalUterine
Bleeding:+• Submucosal
• (FIGOTypes0,1&2)
AbnormalUterine
Bleeding:+/-• Intramural
• (FIGOTypes3,4
&2-5)
AbnormalUterine
Bleeding:-• Subserosal
• (FIGOTypes5,6,7)
HysteroscopicMyomectomy
LaparoscopicMyomectomy
Expectantmanagement
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FIGOCOE(I)N–Iatrogenic/Niches
Hysteroscopicnicheresection
LaparoscopicnicherepairGubbinietal,JMIG,18:234-237,2011&vanderVoetetal,BJOG,121:145-156,2014
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• AsEndometrialAblation(EA)ischaracterizedanymethodthatdestroystheliningoftheuterinecavity(endometrium)
• Itisa“symptomatic”surgicalsolution➢ Target➢ ControlofAbnormalUterineBleeding(AUB)
➢ Minimallyinvasivealternativeto:➢ Medicalmanagement(ifineffective)➢ Hysterectomy
Isendometrialablation/resectionaminimallyinvasivesolution?
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1.Endometriallaserablation
2.Trans-cervicalresectionoftheendometrium
3.EndometrialrollerballAblation
FirstGeneration:HysteroscopicTechniques
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1.Fluid-filledthermalballoonendometrialablation
2.Radiofrequency(thermo-regulated)balloonendometrialablation
3.Hydrothermalendometrialablation
4.MicrowaveEA(MEA)andimpedance-controlledbipolarradiofrequencyablation
SecondGeneration:Non-HysteroscopicTechniques
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EndometrialAblationEfficacy:primaryandsecondaryoutcomes
➢Post-ablationamenorrhea➢ Range:14-55%
➢Post-ablationsatisfactionrate➢ Themostimportantparameterbecausecontrolof
bleedingandnotamenorrheaistherequiredeffect
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0
5
10
15
Hysterectomy 1stGeneraron 2ndGeneraron
10,612,3
5,3
Un-Sa^sfac^onrates
Un-satisfactionratescomparedtohysterectomy
7%higherRR:2.4P<0.001
Battacharyaetal,HealthTechnologyAssessment15:No.19,2011
5,3%higherRR:2.3P<0.001
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0
5
10
15
20
25
Mirena 1stGeneraron 2ndGeneraron
2018,317,2
Un-Sarsfacronrates
Un-satisfactionratescomparedtoMirena
NS
Battacharyaetal,HealthTechnologyAssessment15:No.19,2011
NS
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EndometrialAblationComplications
➢ Fluidoverload&Perforation(1stgenerationTechniques)➢ Infection:early(within3days)orlate(upto50days)
➢ endometritis(1.4–2.0%)
➢ myometritis(0–0.9%)
➢ pelvicinflammatorydisease(1.1%)
➢ Tubo-ovarian,pelvicandcornualabscessorpyometra(0–1.1%)/sepsis
➢ Prevention:antibioticprophylaxis(althoughnotroutinelyrecommended)ortherapywhensuspected
➢ Treatment:hysterectomyanddrainage
Sharp,AJOG,2012
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EndometrialAblationComplications:Postablationpainsyndrome
➢ Post-ablationpainsyndrome(bloodblockedwithinclosedcavities)
➢ Contractureandscarring(duetotissuenecrosisandnon-microbialinflammation)inthepresenceofresidualendometriumcanresultinobstructedegressofmenses
➢ Manifestedashematocavitieswithinthebodyoftheuterinecavity(centralhematometra)oratacornualregion
➢ Clinicalsymptom:cyclicorpersistentpelvicpain
➢ Prevention:avoiddestructionofcervicalcanal,“partial”ablation
➢ Treatment:hysterectomyorhysteroscopicadhesiolysis
Sharp,AJOG,2012
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AbnormalUterineBleeding(AUB)Complications:Inefficientpost-ablationsampling
Inabilitytosampleendometrialcavityincasesofrecurrentbleedingcouldmaskendometrialcancer
➢ Ablationdoesnotincreasetheriskofendometrialcancer
➢ Absolutecontra-indications:Endometrialhyperplasiaanendometrialcancer
➢ Unknownimportanceofriskfactorsforcancerdevelopment➢ Nulliparity&chronicanovulation➢ Obesity&diabetesmellitus➢ tamoxifentherapy➢ hereditarynon-polyposiscolorectalcancer
Sharp,AJOG,2012
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Incidenceofendometrialcancerafterendometrialablationcomparedtothatofgeneralpopulation
Doodetal,JMIG,2014
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EndometrialAblation“Complication”:Post-ablationpregnancy
➢Wishingfuturefertilityisacontra-indicationforendometrialablation
➢ Endometrialablationcouldnotbeconsideredasaformofcontraception
➢ Post-ablationpregnancieshavehigherriskfor➢ ectopicimplantation(reportedincidence2-6%)➢ miscarriages,➢ Pretermdelivery(~30%)andpretermprematureruptureof
membranes(~15%)➢ Abnormalplacentation/placentaaccretapercreta(~25%)leading
inobstetricalhysterectomy(~60%)
Sharp,AJOG,2012
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WhereistheplaceofminimallyinvasivesurgeryinthemanagementofAUB?
ConfirmationofAUB(basedonsymptoms)
DiagnosticWork-up(etiologicalinvestigation)
Treatment(basedondiagnosis)
HysteroscopicEvaluation➢Imagingfindingsneededhistology➢Polyps➢Suspectedendometrialpathology
➢Nofindings➢Biopsyundervision
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WhereistheplaceofminimallyinvasivesurgeryinthemanagementofAUB?
ConfirmationofAUB(basedonsymptoms)
DiagnosticWork-up(etiologicalinvestigation)
Treatment(basedondiagnosis)
Hysteroscopictreatment➢Polyps➢Leiomyomas(Type0-2)➢Adenomyoticcysts➢Noplaceforablation➢NichesLaparoscopictreatment
➢Leiomyomas➢Adenomyosis(mainlyfocal)➢Niches
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THESSALONIKI-GREECE6TH-9THOCTOBER2019
ESGE28THANNUALCONGRESS