Prise en Charge des Saignements Prise en Charge des Saignements AnormauxAnormaux

J-L MERGUIJ-L MERGUIjlmergui@noos.frjlmergui@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