Prise en Charge des Saignements Prise en Charge des Saignements AnormauxAnormaux
J-L MERGUIJ-L [email protected]@noos.fr
I. G.O.Iéna gynécologie Obstétrique
PARIS FRANCE
AUB : 10% of all gynecological visitsAUB : 10% of all gynecological visits
5 à 20% gyne visits after 40y. (Gath 1987)5 à 20% gyne visits after 40y. (Gath 1987)
1 million women in france!1 million women in france!
1/3 are dysfunctionnal1/3 are dysfunctionnal
330 000 women in France !330 000 women in France !
1/3 hysterectomies are done 1/3 hysterectomies are done
without any pathological supportwithout any pathological support
Prévalence
AUB: a subjective symptomAUB: a subjective symptom
- 30% of women with hypermenorrhea(> 80 ml)- 30% of women with hypermenorrhea(> 80 ml)think to have normal mensesthink to have normal menses
- 20 % of women with normal menses < 20 ml - 20 % of women with normal menses < 20 ml think to have AUBthink to have AUB
Need for an objective score : Need for an objective score : Higham ScoreHigham ScoreJanssen ScoreJanssen Score
Reid, Br J Gynecol Obstet, 2000Reid, Br J Gynecol Obstet, 2000
HIGHAMHIGHAM SCORESCORE
Higham Score = 100Higham Score = 100
SS : 80 %SS : 80 %SP : 81 %SP : 81 %
Surgical or medical indication for a TTSurgical or medical indication for a TTif Score > 150if Score > 150
Les troubles hémorragiquesLes troubles hémorragiques
Méthodes utilisables en pratique:
Indolores ou acceptables en consultationPeu coûteusesReproductibles & fiable (SS & SP)Large diffusion territoireaccessibilitéNon Dangereuses
Les troubles hémorragiquesLes troubles hémorragiquescomment les explorer?comment les explorer?
Méthodes à disposition:HystérographieÉchographie:
-vaginale-HSS
Hystéroscopie:-Diagnostique-opératoire
Prélèvement histologique:-aveugle-dirigé
Place de l’HystérographiePlace de l’Hystérographie
HSG versus HSC
HSG HSC
SS polyps 27 70Hyperplasia 25 80Cancer 50 75
PPV Polyps 21 32Hyperplasia 23 55Cancer 33 100
Simon 1993
Place de l’HystérographiePlace de l’Hystérographie
En dehors du Bilan de l’Infertilité
Pas de place pour l’HSGcoûteusedouloureusepeu SS ni SPPas anodinetechnique parfois difficilematériel lourd
Dilatation & curetageDilatation & curetage
D&CD&C
60% ---> endometrial sampling <50% uterine surface 60% ---> endometrial sampling <50% uterine surface Stock 1975Stock 1975
4 à 10% false négatives4 à 10% false négatives Goldrath 1985Goldrath 1985
131 HSC 6 mth after D& Curetage: 60% persistance of anomalies131 HSC 6 mth after D& Curetage: 60% persistance of anomalies Emanuel 1995Emanuel 1995
Method to forget : à oublierMethod to forget : à oublierlow sensitivitylow sensitivityhigh cost (economic & human)high cost (economic & human)bad efficiencybad efficiency
Meno-MétrorragiesMeno-Métrorragies
Echographie vaginale
normale anormale
curetage
hysterosonographie
Hystéroscopie+BE
MétrorragiesMétrorragiesattitude en suèdeattitude en suède
Echographie vaginaleTVS toujours 92%Le + svt 5.8%Normale
Endometre<5mm
AnormaleEndometre >5mm
BE Tjs 66%
HysterosonographieTjs 3%Parfois 63%Jamais 34%
HystéroscopieJamais 44%
MétrorragiesMétrorragiesattitude en suèdeattitude en suède
Echographie vaginale
NormaleEndometre<5mm
AnormaleEndometre >5mm
BE Tjs 31%
Surveillance echo15%
Rien49%
Surv. Echo+ BE5%
Epstein E acta obstet gynecol scand 2004 janEpstein E acta obstet gynecol scand 2004 jan
Hiérarchie des examensHiérarchie des examens
Meno-metrorragiesMeno-metrorragies
NormaleNormale
Persistance Persistance
HSSHSS
Processus intracavitaire Processus intracavitaire
Echographie vaginaleEchographie vaginale
HSC Dg HSC Dg
MyomeMyome
PolypePolype
HyperplasieHyperplasie
CancerCancer
Office HysteroscopyOffice Hysteroscopy
Flexible hysteroscope: Flexible hysteroscope: ø = 3,1mmø = 3,1mm
PainPain NoNo LightLight ImportantImportant mean scoremean scoreHsc typeHsc type (0-10)(0-10)
Flexible/salineFlexible/saline 83 %83 % 15 %15 % 2 %2 % 2.32.3
Flexible/CO2Flexible/CO2 75%75% 20%20% 5%5% 3.13.1
N=1000 N=1000 JL Mergui 2003JL Mergui 2003
OFFICE HYSTEROSCOPYOFFICE HYSTEROSCOPY
Indications for Diag. hysteroscopyIndications for Diag. hysteroscopy
25%25%
25%25%
20%20%
20%20%
8%8%
meno-metro
stérilité
echo atypique
menopause
post-op
divers
26%26%AUBAUB
24%24%infertilityinfertility
19%19%Abn scanAbn scan
21%21%Post-menop.Post-menop.
8%8%
2%2%
N=1000N=1000
Hysteroscopic aspectHysteroscopic aspect after menopause after menopause
JL Mergui N=210JL Mergui N=210
NormalNormal 8% 8% AtrophyAtrophy 40%40% 49% no lesion49% no lesionendometritisendometritis 1%1%
PolypPolyp 20%20%myomamyoma 26%26% 46% benign 46% benign lesionlesion
Atypical hyperplasiaAtypical hyperplasia 2,4%2,4%Invasive AdenoKInvasive AdenoK 2,6% 2,6% 5% Neoplasia5% Neoplasia
HSC versus HSS versus TVSHSC versus HSS versus TVS
SS polypes FP(polypes) SS K FP K
HSS 80% 24% 40% 15%HSC 80% 6% 84% 6%TVS 50% 19% 60% 10%
Epstein E. & coll. Ultrasound obstet gynecol 2001 Aug.
Hystéroscopy / HysterosonographyHystéroscopy / Hysterosonography
N=84 N=84 70% Pre-menop70% Pre-menop 30% Post-menop.30% Post-menop.
SS 94%SS 94%
SP 100%SP 100%pain scorepain score
Tolerance Tolerance HSS HSS 1.51.5HSC HSC 2.1 NS2.1 NS
N.Perrot; JL MerguiN.Perrot; JL Mergui
AUB: french medical guidelinesAUB: french medical guidelines
TVUS + HSCNormalno lésion
What is the best management?
Op. HSC
Intra cavitary organic lesion
LocalisedMyoma, polyp, Adenomyoma
Radical Surgery
Major lesions
Infertility, symptoms, or > 5mmInfertility, symptoms, or > 5mm
AUB: french medical guidelinesAUB: french medical guidelines
TVUS + HSCNormalno lésion
What is the best management?
Op. HSC
Intra cavitary organic lesion
LocalisedMyoma, polyp, Adenomyoma
Radical Surgery
Major lesions
Infertility, symptoms, or > 5mmInfertility, symptoms, or > 5mm
Prise en charge thérapeutiquePrise en charge thérapeutique
-Medical treatments:Medical treatments:*progesterone*progesterone*progestogen *progestogen releasing systems IUD (MIRENA®)releasing systems IUD (MIRENA®) *antifibrinolytic…*antifibrinolytic…
-Operative hysteroscopy:-Operative hysteroscopy:endometrial ablation or associated lesions endometrial ablation or associated lesions
( polyps , myomas, adenomyosis)( polyps , myomas, adenomyosis)
-Thermal ablation: 1st and 2Thermal ablation: 1st and 2ndnd generation generation
-HysterectomyHysterectomy
TCRE versus Medical TT:TCRE versus Medical TT:
Endometrial ablation versus medical treatmentEndometrial ablation versus medical treatment2year follow-up2year follow-up
medical managmentmedical managment endometrial ablationendometrial ablation
NN 8383 8686SatisfactionSatisfaction 57%57% 79%79%
managment acceptablemanagment acceptable 77%77% 93%93%
Recommend treatmentRecommend treatment 24%24% 78%78%
Further surgical procedureFurther surgical procedure 59%59% 17%17%
Short form 36Short form 36 5/8 5/8 (improved)(improved) 7/87/8Cooper K & al. BJOG 1999Cooper K & al. BJOG 1999
TCRE versus progestagen IUD:TCRE versus progestagen IUD:
Endometrectomy versus Levonorgestrel IUD(MIRENA®)Endometrectomy versus Levonorgestrel IUD(MIRENA®) 1year follow-up1year follow-up
endometrial ablationendometrial ablation IUDIUD
NN 3535 3535
Recurrent menorragiaRecurrent menorragia 9%9% 11%11%
Pictorial blood scorePictorial blood scoreReducedReduced 89%89% 79%79%
HypomenorrheaHypomenorrhea 71%71% 65%65%
SatisfactionSatisfaction 94%94% 85%85%
Crosignani PG & al. Obstet gynecol. 1997Crosignani PG & al. Obstet gynecol. 1997
TCRE versus abdominal Hysterectomy:TCRE versus abdominal Hysterectomy:
Endometrectomy versus abdominal hysterectomy:Endometrectomy versus abdominal hysterectomy:
endometrial ablationendometrial ablation hysterectomyhysterectomy
CostCost 560,05 L560,05 L 1059,731059,73 p = 0,0001p = 0,0001
SatisfiedSatisfied 79%79% 96%96% p = 0,002p = 0,002
Choose sameChoose same
ProcedureProcedure 76%76% 94%94% p = 0,002p = 0,002
Premenstrual Premenstrual
Synd.persist.Synd.persist. 57%57% 23%23%
Time off workTime off work 23%23% 4% 4% Sculpher M. BJOG 1996Sculpher M. BJOG 1996
TCRE versus vaginal hysterectomy:TCRE versus vaginal hysterectomy:
Endometrectomy versus vaginal hysterectomy: (N=200)Endometrectomy versus vaginal hysterectomy: (N=200)
endometrial ablationendometrial ablation hysterectomyhysterectomy
Operative timeOperative time 13mn13mn 71mn71mn p<0,001p<0,001Hosp. StayHosp. Stay 11 5 days5 days p<0,001p<0,001Time off workTime off work 1414 30 days30 days p<0,001p<0,001SatisfiedSatisfied 87%87% 95%95% p = 0,26p = 0,26
Short Form36 (24 months later)Short Form36 (24 months later)Social funct.Social funct. 7070 8080 p=0,04p=0,04VitalityVitality 5252 6363 p=0,01p=0,01Hosp.anxietyHosp.anxiety 6,86,8 5,25,2 p=0,03p=0,03DepressionDepression 4,74,7 4,14,1 p=0,03p=0,03
Crosignani PG & al. AJOG 1997Crosignani PG & al. AJOG 1997
Endometrial ablation by TCREEndometrial ablation by TCRE
endometrial resection by resectoscope:endometrial resection by resectoscope:
resultsresults
histologyhistology N N %% successsuccess failurefailure
NormalNormal 5050 20%20% 4848 2 ( 4%)2 ( 4%)
HyperplasiaHyperplasia 7070 28%28% 6666 4 ( 6%)4 ( 6%)
MyomaMyoma 4848 20%20% 4444 4 ( 8%)4 ( 8%)
AdenomyosisAdenomyosis 8080 32%32% 5959 21 (26%)21 (26%)
TotalTotal 248248 100%100% 217217 31 ( 12,5 % )31 ( 12,5 % )ComplicationsComplications
mecanikmecanik 11 0,5%0,5%electrikelectrik 00biologikbiologik 0 0 JL Mergui Tenon Paris
Thermal ablationThermal ablation
First generationFirst generation
Second generationSecond generation
THERMAl ablationTHERMAl ablation
8 minutes of 8 minutes of treatementtreatement- Temperature of - Temperature of 87°c87°c
during during 8 minutes.8 minutes.
-external diameter 4.5mm-external diameter 4.5mm
-pressure 160-180 mm Hg-pressure 160-180 mm Hg
equipmentequipment
CRYOCOAGULATIONCRYOCOAGULATION
Effect on specimenEffect on specimen
Micro-waves Micro-waves
Technic of micro wavesTechnic of micro waves
Hydro-Thermal-Ablation (HTA)Hydro-Thermal-Ablation (HTA)
Bipolar Thermo Ablation Bipolar Thermo Ablation
COMPARE methodsCOMPARE methods
time diametershape
influenceballoon 8 mn 4-5 mm +Cryoablation 10-20 mn 5,5 mm ?radiofréquency 8-10 mn 8 mm +Bipolar diathermy 1,5 mn 4 mm +HTA 17 mn 8 mm -Micro waves 1-4 mn 8 mm +Elitt laser 7 mn 6 mm +
Traitement controverses:Traitement controverses:
-1 Medical TT ou chirurgie?-1 Medical TT ou chirurgie?
The Cochrane collaboration 2006 Marjoribanks J, Lethaby A; Farquhar C
The Cochrane collaboration 2006 Marjoribanks J, Lethaby A; Farquhar C
The Cochrane collaboration 2006 Marjoribanks J, Lethaby A; Farquhar C
The Cochrane collaboration 2006 Marjoribanks J, Lethaby A; Farquhar C
The Cochrane collaboration 2006 Marjoribanks J, Lethaby A; Farquhar C
The Cochrane collaboration 2006 Marjoribanks J, Lethaby A; Farquhar C
The Cochrane collaboration 2006 Marjoribanks J, Lethaby A; Farquhar C
Treatment controversies:Treatment controversies:
2- which method of Hysteroscopic2- which method of Hysteroscopicablation ?ablation ?
Laser / rollerball/ TCRE ?Laser / rollerball/ TCRE ?
The Cochrane collaboration 2006 Lethaby A; Hickey M, Garry R
The Cochrane collaboration 2006 Lethaby A; Hickey M, Garry R
The Cochrane collaboration 2006 Lethaby A; Hickey M, Garry R
Treatment controversies:Treatment controversies:
3- Thermal ablation or TCRE ?3- Thermal ablation or TCRE ?
Hysteroscopic or Hysteroscopic or non hysteroscopic method?non hysteroscopic method?
The Cochrane collaboration 2006 Lethaby A; Hickey M, Garry R
The Cochrane collaboration 2006 Lethaby A; Hickey M, Garry R
The Cochrane collaboration 2006 Lethaby A; Hickey M, Garry R
The Cochrane collaboration 2006 Lethaby A; Hickey M, Garry R
Quelle strategieQuelle strategieComment choisir une Comment choisir une
méthode?méthode?
AUB: french medical guidelinesAUB: french medical guidelines
TVUS + HSCNormalno lésion
Medical TT
Failure Op. HSC
Intra cavitary organic lesion
DiffuseLocalised
Radical Surgery2nd generation
Thermo ablation.
IUD LevoN.
Major lesions
Peri & Post-menopause
Prendre en charge les meno - metrorragies:Prendre en charge les meno - metrorragies:
-Évaluer les symptômes et leurs conséquences-Évaluer les symptômes et leurs conséquences
-Rechercher une lésion organique-Rechercher une lésion organique
-Informer les patientes et leur famille-Informer les patientes et leur famille
-Pour choisir la meilleure stratégie thérapeutique:-Pour choisir la meilleure stratégie thérapeutique:
traiter les lésions associéestraiter les lésions associées
choisir en fonction de son expériencechoisir en fonction de son expérience
de son équipementde son équipement
du désir des patients et de leur fertilitédu désir des patients et de leur fertilité
du système économique de sa régiondu système économique de sa région