The Gynecologist’s Role in Evaluation and Management of HMB

Andra H. James MD, MPH Consulting Professor,

Obstetrics & Gynecology Duke University Medical Center

Sponsored by Texas Children’s Hospital & The Foundation for Women and Girls with Blood Disorders

Monday, May 18, 2015 Feigin Center, 14th Floor, Conference Room 14D

1:00pm – 5:00p.m.

Speaker: Andra H. James, MD, MPH

Duke Medicine, Consulting Professor

Topic: “Gynecologists Role in Evaluation and Management of HMD”

   Planning  Commi+ee  DISCLOSURE:    Dr.  James  is  referencing  an  unlabeled/unapproved  drug  or  product  in  her  presenta9on.  The  drugs  referenced  are  normal  contracep9ves  and  proges9n  contracep9ves  for  the  treatment  of  heavy  menstrual  bleeding.                

Overview

1.  Establish the presence of HMB 2.  Consider the possible causes 3.  Evaluate for uterine pathology 4.  Evaluate for systemic causes

-anovulation 2⁰ to systemic disease -underlying bleeding disorder

5.  Utilize hormonal or surgical therapy as appropriate

ACOG    Commi@ee  on  Adolescent  Health  Care    

 American Academy of Pediatrics

DEDICTED TO THE HEALTH OF ALL CHILDRENTM

Committee on Adolescence

Is it HMB?

4  

Committee Opinion            Menstruation in Girls and Adolescents: Using the Menstrual Cycle as a Vital Sign    

Number  349,  November  2006    

Age of first period 11 to 14 years Length of cycle 21 to 45 days Length of period 7 days or less Product use 3 to 6 pads or tampons per day

PALM-COEIN Classification of Abnormal Uterine Bleeding

5  Munro, et al. for the FIGO Working Group on Menstrual Disorder, Int J Gynaecol Obstet. 113:1-13, 2011

polyp  adenomyosis  leiomyoma  (fibroids)  malignancy  and  hyperplasia  coagulopathy  (bleeding  disorder)  ovulatory  dysfunc9on  (anovula9on)  endometrial  iatrogenic  not  yet  classified  

PALM-COEIN Classification of Abnormal Uterine Bleeding

6  

polyp  adenomyosis  leiomyoma  (fibroids)  malignancy  and  hyperplasia  coagulopathy  (bleeding  disorder)  ovulatory  dysfunc9on  (anovula9on)  endometrial  iatrogenic  not  yet  classified  

Munro,  et  al.  for  the  FIGO  Working  Group  on  Menstrual  Disorder,  Int  J  Gynaecol  Obstet.  2011;  113:1-­‐13  

Netter medical illustration used with permission of Icon Learning Systems, LLC a subsidiary of MediMedia, USA, Inc. All rights reserved.

Fibroids as an Example of Local Pathology

7  

PALM-COEIN Classification of Abnormal Uterine Bleeding

8  Munro,  et  al.  for  the  FIGO  Working  Group  on  Menstrual  Disorder,  Int  J  Gynaecol  Obstet.  2011;  113:1-­‐13  

polyp  adenomyosis  leiomyoma  (fibroids)  malignancy  and  hyperplasia  coagulopathy  (bleeding  disorder)  ovulatory  dysfunc9on  (anovula9on)  endometrial  iatrogenic  not  yet  classified  

The Menstrual Cycle

9  

Cause Age  13-­‐19

Age  20-­‐34

Age  35-­‐49

Age  50+

Adolescent  anovula9on

Bleeding  disorder

Local  pathology

New  systemic  disease

An9coagulant  therapy

Post-­‐op  complica9on

Hypothyroidism

Peri-­‐menopausal  anovula9on

Causes of Heavy Menstrual Bleeding  

 

10  

Evaluation of HMB: History

History •  obstetrical

•  currently pregnant?

•  gynecological • menstrual •  sexual •  recent trauma?

•  medical •  bleeding history

Image  source:  Microso]  Clip  Art  online  

Evaluation of HMB: History

Medications •  contraceptives and

hormones • anticoagulants and

antiplatelet agents •  thyroid medications

Image  source:  Microso]  Clip  Art  online  

Evaluation of HMB: Examination •  vital signs •  oxygen saturation •  speculum exam and pelvic examination

per gynecologist – depending on the age of the patient and the clinician’s judgement

Evaluation of HMB: Ultrasound •  Endovaginal assessment of the pelvis •  Abdominally for adolescent who has not

been sexually active

Evaluation of HMB: Ultrasound

•  Endometrial sampling if > age 45 •  < age 45 if history of unopposed estrogen

Screening for Bleeding Disorders in Women with HMB

16  Document  source:  h@p://www.cdc.gov/ncbddd/blooddisorders/women/documents/menorrhagiafortes9ng.pdf  

How to use the screening tool

17  

The screening tool is considered positive if: 1.  The duration of menses was greater than or

equal to 7 days and the woman reported either “flooding” or bleeding through a pad or tampon in 2 hours or less with most periods

2.  A history of treatment of anemia 3.  A family history of a diagnosed bleeding

disorder, or 4.  A history of excessive bleeding with tooth

extraction, delivery or miscarriage, or surgery

Laboratory Evaluation •  pregnancy test

James et al. Von Willebrand disease and other bleeding disorders in women: consensus on diagnosis and management from an international expert panel. Am J Obstet Gynecol, 2009

Work-Up for a Bleeding Disorder

The laboratory assessment should include, as necessary:

•  CBC •  prothrombin time (PT) •  activated partial thromboplastin time (aPTT) •  VWF:RCo, VWF:Ag and FVIII •  platelet function (platelet aggregation studies) •  other clotting factors •  other non-hematologic tests including, perhaps, tests

of thyroid function

James et al. Von Willebrand disease and other bleeding disorders in women: consensus on diagnosis and management from an international expert panel. Am J Obstet Gynecol, 2009

 

Types of Bleeding Disorders in Female UDC (n = 319)*

20  

Total  VWD   88.7%      Type  1   61.1  %      Type  2   7.8  %      Type  3   4.4  %      Type  unknown   15.4  %  Factor  VIII   12.5%  Platelet  disorders   4.7%  Missing  diagnoses   6.9%  Other  bleeding  disorders   15.4%  

*19.4%  had  2  or  more  hemosta9c  defects      *Byams et al, Haemophilia. 17(Suppl 1):6-13

Management of HMB Algorithm for management of VWD-related menorrhagia

Hormonal measures(in order of efficacy):1. Levonorgestrel IUS2. Combined hormonal contraceptives3. Progestins

Treatment plan in conjunction with an

expert in hemostasis

Would the patient like to preserve fertility?

Would the patient like to become pregnant now?

Can also consider:• Hysterectomy• Endometrial ablation

YES

NO

NO

YES

Decision tree that outlines the algorithm for the determination of the best management strategy of von Willebrand disease-related menorrhagia that is based on future fertility. Hemostatic agents and hormonal measures can be combined as needed. Adapted from James, et al (2009).

Reference: James AH, Kouides PA, Abdul-Kadir R, et al. von Willebrand disease and other bleeding disorders in women: consensus on diagnosis and management from an international expert panel. Am J Obstet Gynecol. 2009; 201:12.e1-e8.

Watchful Waiting in the Adolescent

•  Follow pubertal progression closely – Menarche is, on average, 2 years behind

telarche (growth velocity peak) – Maintaining fertility is critical

•  Hysterectomy is not an option •  Work with a hemostasis expert and have

a well-designed plan in place – Both hormones and hemostatic agents may

be necessary

James AH. Bleeding disorders in adolescents. Obstet Gynecol Clin N Am. 2009; 36(1):153-162.

Starting Hormones in Adolescents1,2

•  Levonorgestrel intrauterine system (IUS)1,2

•  Combined hormonal contraceptives1,2

•  Progestins1,2

•  Can be started at menarche, but not before

– Starting early may interfere with growth

References: 1. James AH. Bleeding disorders in adolescents. Obstet Gynecol Clin N Am. 2009;36(1):153-162. 2. Kadir RA. Menorrhagia: treatment options. Thromb Res. 2009;123(suppl 2):S21-S29.

Endometrial Ablation1,2

•  Advantages compared with hysterectomy – Shorter procedure3

– Faster recovery3

– Reduced cost3

– Fewer adverse events3

•  Disadvantages – Future surgery3

– Greater long-term blood loss References: 1.  Sambrook AM, Bain C, Parkin DE, Cooper KG. A randomised comparison of microwave endometrial ablation with transcervical resection of the endometrium: follow

up at a minimum of 10 years. Br J Obstet Gynecol. 2009;116:1033-1037. 2.  Chapa HO, Venegas G, Antonetti AG, Van Duyne CP, Sandate J, Bakker K. In-office endometrial ablation and clinical correlation of reduced menstrual blood loss

and effects on dysmenorrhea and premenstrual symptomatology. J Reprod Med. 2009;54:232-238. 3.  Lethaby A, Shepperd S, Farquhar C, Cooke I. Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding (review). Cochrane Syst Data

Rev. 1999;2(1):1-60.

Hysterectomy1-4 •  Patient satisfaction reported to be comparable to or

higher than that for other methods3 •  Potential for serious morbidity, including perioperative

bleeding4 –  Bleeding complications during hysterectomy occur in

3% of patients with VWD compared to <1% of women without VWD5

•  Plan required to avoid/control bleeding •  Aspirin and NSAIDs to be avoided post-op6 •  Potential for complications should not keep women who

need the procedure from having it6

References: 1. Munro KG. The evolution of uterine surgery. Clin Obstet Gynecol. 2006;49(4):713-721. 2. Hoffman MS. Extent of radical hysterectomy: evolving emphasis. Gynecol Oncol. 2004;94:1-9. 3. Lethaby A, Shepperd S, Farquhar C, Cooke I. Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding (review). Cochrane Syst Data Rev. 1999;2(1):1-60. 4. Maresh MJA, Metcalfe MA, McPherson K, et al. The VALUE national hysterectomy study: description of the patients and their surgery. Br J Obstet Gynecol. 2002;109:302-312. 5. James AH, Myers ER, Cook C, Pietrobon R. Complications of hysterectomy in women with von Willebrand disease. Haemophilia. 2009;15(4):926-931. 6. National Heart, Lung, and Blood Institute. The Diagnosis, Evaluation, and Management of von Willebrand Disease. Bethesda, MD: US Department of Health and Human Services; 2008.

Treatment for HMB (n = 165) in the UDC

26  

Oral  contracep9ves   90  (54.5%)  Desmopressin   56  (33.9%)  An9fibrinoly9cs   40  (24.2%)  Blood  or  plasma  products   12  (7.3%)  Cloang  factor  products   10  (6.1%)  Endometrial  abla9on   7  (4.2%)  Levonorgestrel  IUD   5  (3.0%)  Uterine  artery  emboliza9on   3  (1.8%)  Platelet  transfusion   1  (0.6%)  

21/198  (10.6%)    menstrua9ng/menopausal  women  with  HMB  underwent  hysterectomy  specifically  to  control  HMB  

Byams,  et  al.  Haemophilia,  17(Suppl  1):6-­‐13  

Summary

1.  Establish the presence of HMB 2.  Consider the possible causes 3.  Evaluate for uterine pathology 4.  Evaluate for systemic causes

-anovulation 2⁰ to systemic disease -underlying bleeding disorder

5. Utilize hormonal or surgical therapy as appropriate

Thank  you      Gracias        Merci  

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