Essay 285 - Abnormal uterine bleeding

A 36 year old mother of 2 children has been referred to the gynaecology clinic because of heavy menstrual bleeding that has not responded to first line therapy by her general practitioner. (a) Discuss the information you will obtain from the history [5 marks]. (b) Justify the investigations you would undertake [3 marks]. (b) A diagnosis of AUB-E is made. Critically evaluate the surgical options for treating her symptoms [12 marks].

A) Duration and severity of the bleeding are noted. She should be  asked about clotting, flooding and effect of bleeding on her quality of life.  

Present and previous menstrual history is taken which includes age of menarche, regularity, cycle length, flow and LMP.  Symptoms of fatigue, shortness of breath and palpitations suggest anaemia. Additional symptoms like dysmenorrhoea and premenstrual tension are asked. 

She is asked about the method of contraception and her future reproductive intensions.

Obstetric history is taken regarding the mode of child birth . In case if she needs surgical treatment for the menstrual bleeding, previous CS is associated with risk of visceral injury .

Details are asked about previous treatment, her concerns and expectations.  

She is asked about any history of post partum haemorrhage, bleeding after dental procedures, bruising and family h istory of bleeding disorders.

She should be asked if she has suffered anovulatory infertility or is treated with tamoxifen which are risk factors for endometrial hyperplasia. She should be asked if she has diabetes or hypertension which predispose to endometrial carcinoma. History is taken if she is receiving any anticoagulant therapy.  

B) CBC is done to exclude anaemia. In the presence of positive history is clotting screen and further evaluation to identify bleeding disorders in conjunction with haematologist.

TVS is a preliminary screening tool to identify the presence of uterine structural abnormalities like fibroids. But it is not 100% sensitive to detect polyps and sub mucous leiomyoma. MRI is essential to evaluate myometrium in differentiating leiomyoma and adenomyosis.  Hysteroscopy is required to identify endometrial polyps.

C) It is ensured that her family is complete before proceeding to surgical management as all the surgical options are associated with loss of reproductive potent.

Endometrial ablative techniques aim to reduce menstrual bleeding by  ablation of entire endometrium by electrical , thermal or laser energy.  They less invasive and use fewer resources than hysterectomy and done as day care procedure. 

First generation endometrial ablation techniques like TCRE require visualisation of the uterine cavity  and more operator dependant. Associated with fluid overload . Amenorrhoea rate of 20- 40%. Long term satisfaction rate of 80%. Re operation rate is about 38%. The other adverse effects are Uterine perforation – 11-14 per 1000 and risk of haemorrhagege. She needs to continue contraception as there is risk of pregnancy.

Sencond génération endometrial ablation techniques are less operator dependant and include thermal balloon or microwave endometrial ablation. Thermal balloon technique includes use of cavaterm or themachoice. Cavaterm thermal balloon ablation cannot be used if the uterine cavity is more than 10 cm and Thermachoice should not be used if more than 12 cm. Complications of balloon thermal ablation included endometritis, perforation, urinary tract infection and haemorrhage

Microwave endometrial ablation technique can be used in uterine cavities which are irregular. Complications of microwave endometrial ablation include perforation of the uterus, minor secondary haemorrhage, and burning of the vagina, cervix and small bowel.

The other surgical option is  hysterectomy which is a definitive treatment particularly if she desires amenorrhoea.

Abdominal hysterectomy is associated with more morbidity compared to vaginal hysterectomy but allows inspection of other abdominal viscera like ovaries.  Subtotal hysterectomy is associated with less operating time, lesser blood loss and reduced incidence of vault prolapse. The disadvantages are occasional bleeding from the residual endometrium, and a risk of stump carcinoma is about 0.3%. She has to continue  cervical screening.

Laparoscopic hysterectomy is associated with better cosmetic effect, lesser intraoperative blood loss, shorter hospital stay, faster recovery as well as reduced post operative pain and analgesic requirement. The risk of visceral injury is about 3/1000. Requires experienced surgeon and equipment.

A) A structured menstrual history to identify the cause of heavy menstrual bleed has to obtained. Regular cycles 22- 35 days with heavy predictable flow , likely to be ovulatory AUB . Irregular unpredictable bleeding , heavy prolonged flow, oligomennorhoea, amennorrhoea follwed by bleeding likely to be anovulatory. Intermenstrual , postcoital bleed suggests structural cause like polyps, chlamydial infection,cervical malignancy.Menorrhagia with significant cyclical dysmennorhoea , suggestive of  adenomyosis.Associated Pelvic pain , pressure , distention to rule out fibroids.L.MP. has to enquired.Severity & Quality of life assesment, like work absenteism, interference with routine activities.

Obstetric history : Normal or vaginal deliveries , for surgical risk assessment. Future fertilitydesires for planning treatment .Contraceptive usage IUCD, LNG - IUG DMPA or any contraceptive usage to assess compliance, breakthrough bleeding or side effects of usage.Drug history : Drugs : like anticoagulants, which may cause bleeding or Phenothiazines , amitrytaline which may interfere with ovulation. The treatment history which GP has given. History suggestive of any coagulatory disoredrs lke family history, easy bruising , gum bleeding , epistaxis.Smear history . Any recent change of partner.History of weight gain , acne ,increased hair growth - PCO. Weight gain , constipation, cold intolerance - thyroid disorders. Family history of HNPCC,bleeding disorders.

B) Since first line treatment has failed she needs clinical assessment & investigation .

CBC to evaluate anemia. Clotting prolie if history suggests bleeding disorders in liason with a hemmatologist.  Thyroid functions if clinically indicated only . Basal hormones : LH , testosterone levels on day 1-5 if clinical symptoms of PCO.  Endocervical sampling for chlamydia if Intermenstrual bleed or post coital bleed or sexual history suggestive of high risk. Transvaginal usg for evaluation of endometrium thichness for hyperplasia , polyp,fibroids ,myometrial heterogenicity suggestive of adenomyosis,  rule out fibroids, ovariam morphology for PCO, endometriosiscause .  Endometrial biopsy  to rule out any hyperplasia or malignancy if history suggests chronic hyperestrogenism like obsity , PCO or family h/o HNPCC. Hysteroscopy and biopsy if focal causes of polyp. fibroid polyp suspected.

C) Surgical options include uterus conserving procedures like endometrial ablation or  definitive Rx like Hystrectomy - depends on patient wishes  & future fertility issues, after discussing the benefits & risks of each procedure and making an informed consent.Alternate non surgical treatment options like LNG IUS should also be discussed.

Endometrial resection / ablation : Prerequsite : endometrial cavity assessed completely & hyperplasia or malignancy to be ruled out . Adavntage : avoids hystrectomy ,less invasive , quicker recovery, uses less resourses, improves HB, QOL, High patient satisfaction rate - 80%. Amenorrhoea - 20-40 % . Disadv : May require hysterctomy at later date 10-25 % at 3-4 years , reoperation rate 38%, uterine perforation 11/1000. Cycical pain experienced by some women , no clear data however .Used only for women not desirous of future pregnancy. Contraception still adviced after procedure as still risk of pregnancy present.minor side effects hemmorhage, infection, fever.

First generation devices:TCRE/ roller ball : needs hystroscopy & visualisation for endometrial resection , henceGA . Risks of Fluid overload ,cardiac failure , hyponatremia discussed. Preop endometrial thinning reguired. Second generation: thermal ballon / microwave commonly used. : Doesnt require preop thinning of endometrium ,can do done under local anaestehesia as daycase , does not require hysteroscopy .

Hystrectomy : for women strongly in desire of amennorhoea, not wishing to reatin fertity or uterus, or failed conservative surgical endometrial ablation. Advantage : definite  Rx,high satisfaction, amenorrhoea gauranteed. disadvantage : surgical & anaesthetic risks. Advantages of subtotal discussed : Less operative time , intraop bleeding , visceral injury, less post op infection, vault granulation, secondary hemorrhage. Long term dysfunction on bowel or bladder not demonstrated. Sexual dysfunction in observational studies show improved satisfaction due to cervical secretion & lubrication, not shown in RCTs. Disadv : need continued cervical screening , inor risk of bleed from remnants, cervical stump ca 0.3%.

Vaginal hystrectomy : less time, quicker recovery, discharge from hospital ,less pain,cost effective slightly higher risk of bladder injuries,ovaries less accessible, needs vaginal descent and accessability. Laproscopy : Less invasive , faster recovery ,less pain visualisation of abdominal organs, less hemorrhage. Risk of visceral injury rare .Needs expertise .

Discuss oophorectomy : no need to remove healthy ovaries.Discuss pt wishes, high risk like BRCA descendent may wish prophylactic oophorectomy. discuss HRT if planning oophorectomy, oophorectomy reduces risk of ovarian ca and breast ca but does not eliminate the risk.  Provide written information & contact numbers for further discussion and consent .

A) I would ask her to quantify the amount of bleeding in terms of number of pads changed, production of clots and whether the bleeding is so heavy as to overflow her pad. I would also ask about the duration of symptoms, whether there is associated pain, if her cycles are regular and if there is intermenstrual bleeding. 

I would ask about any personal history of fibroids or adenomyosis, and any family or personal history of gynaecological cancers and bleeding disorders. I would also ask about other medical problems such as hypertension and diabetes that might put her at higher surigcal risk. I would enquire about treatment given by the general practioner and how efficacious the treatment was, as well as any other medication she is on, such as warfain which might increase blood loss. I would ask for symptoms of anaemia such as dizziness and lethargy, and also ask about future fertility plans. 

B) I would do a full blood count to look for presence and degree of anaemia. I would also perform a pelvic ultrasound scan to look for uterine pathology such as fibroids and adenomyosis, as well as endometrial pathology such as endometrial polyps and grossly thickened endometrium. If the change in bleeding pattern is new and she has associated risk factors for endometrial cancer, I would either perform an endometrial biopsy or a hysteroscopy with dilation and currettage to rule out endometrial hyperplasia and cancer. 

C) The surgical options would depend on her desire for future fertility as well as desire to preserve her uterus. Endometrial ablation may be done using either first or second generation methods. These methods are suitable if the patient has fibroids under 3cm and are preferred over hysterectomy if the uterus is 10 weeks sized or smaller. They are associated with 70-90% reduction in bleeding levels at 12 months and up to 40% amenorrhea 12 months after treatment. However long term results are inferior to hysterectomy, as up to 30% require further treatment in the form of repeat hysterectomy or ablation at 12 months post-procedure. 

First generation methods such as rollerball ablation or transcervical resection of endometrium may done as day surgery procedures, while second generation methods have the advantage of being performed outpatient or as day surgery cases. Success rates for second generation methods are also less operator dependent and are simpler faster to perform. While both first and second generation methods are associated with the risks of bleeding, infection, perforation and electrosurgical burns, first generation methods have the added risks of fluid overload leading to cardiac failure, hemolysis and death, while second generation methods have risks of hematometra and cyclical pain. Both first and second generation methods are contraindicated if fertility is desired, if there has been a previous caesarean section and if there is endometrial malignancy or pre-malignancy.

Hysterectomy is the definitive treatment but may only be done if the patient consents to removal of the uterus and does not desire future fertility. The ovaries should be conserved in view of her age. The overall risk of serious complications from  hysterectomy is 4/100 and include injury to bladder and/or ureter, bowel damage, bleeding requiring transfusion, return to theatre for bleeding or wound dehiscnece, pelvic abscess, venous thrombosis and death. The incidence of serious complications is higher than that of endometrial ablation.Frequent risks include wound infection, numbness around scar, ovarian failure and urinary tract infection. 

Hysterectomy may be done via the vaginal, abdominal, laparoscopic or robotic approach. Vaginal hysterectomy is the method of choice. It is associated with shorter hospital stay, faster return to normal activity and fewer febrile episodes or unspecified infections than abdominal hysterectomy, and shorter operating time than laparoscopic hysterectomy. Vaginal hysterectomy may however be more difficult if there is a history of previous surgery or presence of adnexal pathology. If vaginal hysterectomy is not feasible, then laparoscopic approach is preferred to laparotomy as it is associated with shorter hospital stay, faster return to normal activity, smaller drop in haemoglobin and intra-operative blood loss, fewer wound infections. There is however a high risk of lower urinary tract injury.  

(a) From the history I need to know for how long she is having this problem. I will ask about symptoms suggestive of local pathology. This includes pressure symptoms which might occur with fibroids. It is important to know if she is having intermenstrual bleeding suggesting cervical pathology. Concerning the medical history I will need to know if she has hypertension or diabetes mellitus as these might be risk factors for endometrial malignancies. I will need to know if she is taking anticoagulant or has bleeding disorders. I will ask about symptoms suggestive of thyroid disease including weight  gain, appetite, hair loss or cold intolerance.  regarding the obstetric history I will ask about preterm deliveries, or miscarriages specially 2nd trimester which might suggest local uterine lesions.  As for menstrual history I need to ask about the age of menarche, LMP and the regularity of the periods. I will ask about associated dysmenorrhea  suggesting pelvic pathology or infection. History of contraception is important regarding the type of contraception used, and check how consistent is the administration. Injectable contraception may be associated with abnormal uterine bleeding. the IUCD may cause heavy menstrual bleeding. Family history of endometrial cancers, breast cancer or ovarian cancer is important. I will ask about family history of non polyposis colorectal cancer as it is associated with high risk of endometrial cancer.

(b) Full blood count should be done to check for anaemia. Also it is important to do a pregnancy test. Pelvic ultrasound is necessary to check for local lesions including fibroids, or adnexal masses. TAS is suitable for large masses or fibroids. TVS for assessment of the ovaries, and endometrial thickness or presence of polyps. Fibroids are associated with abnormal uterine bleeding. Having failed to respond to the first line medical treatment an endometrial biopsy is necessary to exclude endometrial malignancy. Cervical smear should be done if due.

(c) The surgical options include endometrial ablation, uterine artery embolisation for fibroids, Myomectomy or hysterectomy. The choice is guided by her desire to preserve her fertility. regarding the fibroids the choice of having UAE is considered if she does not desire to get pregnant, also she is willing to use contraception. The risk of having miscarriage is high following UAE. Myomectomy can be done if she desires to preserve her fertility, however, she should know that abdominal myomectomy is associated with high risk of adhesions resulting in tubal block. Also during myomectomy the endometrial cavity may be breached and she will need to deliver by cesarean section. Regarding submucous fibroids < 5 cm deforming the uterine cavity may be removed by hysteroscopy. this modality might need several times to be totally removed.

The endometrial ablation may be suitable if the uterine size is less than 12 cm and the cavity is uniform. The second genration techniques are more suitable. Again, ablation cannot be used if she is desiring pregnancy. she should be willing to use contraception. Also she should be willing to have hysterectomy if the procedure fails to achieve adequate results. she should know some women will have amenorrhea and others will still have periods.

hysterectomy is always kept as last resort, If other modalities have failed. The ovaries should generally be preserved unless there is a pathology. When choosing hysterectomy it can be done vaginally, laparoscopic assisted or abdominally. The Abdominal hysterectomy is associated with greater morbidity and hospital stay.

SAQ   Abnormal uterine bleeding

A History The patient is asked detailed menstrual history like age at menstruation, last menstrual period, duration and frequency of menstrual cycle, how long she is suffering from it, amount of bleeding like flooding or clots for subjective assessment of amount of blood loss.   Related symptoms like intermenstrual bleeding, postcoital bleeding, dysmenorrhea, dyspareunia, will point towards structural cause and premenstrual symptoms like cyclical mastalgia and migraine is enquired. The effect of symptoms on her quality of life like weakness, fatigue, breathlessness, and time off from work will tell about severity of problem. History of previous pregnancies, mode of deliveries, caesarean section, or pelvic surgeries asked. Any history of suspected pregnancy and previous miscarriages and future fertility desires along with expectations for relief of symptoms would help to plan management. History of contraception, cervical smear history asked. Any family history of bleeding disorder, coagulation defects history of breast or ovarian cancer, or taking drugs like warfarin, phenothiazines, hormonal therapy. How long is she taking treatment and what drugs is she taking for her symptom control. 

B Investgations   Full blood count to see Hb level. Trasnvaginal ultrasonography/TAS for uterine polyp, fiboid, adenomyosis, or adenexal masses is first line investigation . Pipelle biopsy if treatment ineffective or failure or risk factors for endometrial malignany present. Chalymedia infection screening which can be associated with HMB.MRI may be required for accurate mapping of fibroids if not possible with transabdominal scan. Thyroid function tests if symptoms of disorder.

C Treatment   The patient medication is reviewed. If she has not tried Mirena or LNF-IUS then she can be given the option as it safe, effective, non invasive acts by local endometrial atrophy, reduces blood loss by 80% and after 1 year use it is 90% with high satisfaction rate. It can cause irregular bleeding during first 3-4 months.

Surgical options include Endometrial ablation techniques, uterine artery embolization, or hysterectomy. The patient is given full information, written information about risks and benefits of each option, and depending upon her individual cicumstances, her fertility desires, and severity of symptoms she is supported in decision-making. Endometrial ablations are safe, less invasive and does not involve risks of major surgery. These techniques involve destroying endometrial lining with use of electrical, thermal or laser energy. First generation techniques are transcervical resection of endometrium and rollerball endometrial resection. These depend on skill and expertise of operator and direct removal of endometrial lining up to basalis layer using an electrode or roller ball. This requires direct hysteroscopic visualization of endometrial cavity. The uterine size should not be more than 10week size, any infection or structural cause is excluded, she should not need future fertility and amenorrhea is not guaranteed. Second generation techniques are thermal balloon endometrial resection and microwave endometrial ablation. These involve insertion of balloon inside uterine cavity, filling it with fluid which is heated up to 70-80 degree c. these are safer and rely on safety and efficacy of the device itself. Endometrial hyperplasia and malignancy should be excluded before these procedures. Amenorrhea rate is 60-70%but may need repeat operation after 3 years. Risks include thermal injuries, uterineperforation, haemorrhage, infection, injury to bladder or bowel.

Uterine artery embolizations involve blocking of uterine arteries under ultrasound guidance by interventional radiologist. This is uterus preserving, fertility preserving option but requires multidisciplinary management. Future pregnancy can occur but involves complications like miscarriage and preterm labour. Complications of this procedure are post embolism syndrome and infection, which needs urgent evaluation and treatment with antibiotics.

Hysterectomy is last option if she does not need fertility, not to conserve uterus, and wants definite relief of symptoms. Detailed counselling is required about risks and benefits of major surgical procedure. It can be vaginal or abdominal or laproscopic assisted. Choice of procedure depend upon individual circumstances. Total abdominal hysterectomy or subtotal abdominal hysterectomy is discussed and decision regarding conservation or removal of ovaries depends on clinical condition and patient wishes.   Risks of TAH include haemorrhage, damage to bowel, bladder, infection, risks of anaesthesia, thromboembolism. Vaginal hysterectomy less invasive and early recovery occurs. Laproscopic hysterectomy involves injury to ureter, bladder and major blood vessel.

a)To know for how long she had this problem and for how may days she gets heavy menstrual bleeding ,also if associated with clotts or flooding;so as to think of pssibility of anemia.History of intermenstrual bleeding or postcoital bleeding.Also I will enquire about the impact of this complaint on her life.Hx of contraception use and which one exactly.If the patient has been subjected to to cerviacal screening programme.Her fertility wishes because this will affect management options.                                   b)After proper clinical assessment which include speculum exam.Labrotory :full blood count is very important and a must for such complaint.Ferritin level not to be routine.Thyroid function testif clinicaly indicated.Imaging:Transvaginal scan is very important to determine endometrial thickness,more than 12mm in follicular phaseis thought for more invest,also to detect polyps or fibroids.endometrial sampling  or hesterscopy .                 c)surgical options:HYSTERECTOMY:this option is appropriate if the lady does not wish to reserve her fertility ;it eliminate the problem and she should be counselled about either:TAH,VHor LAVH in absence of malignancy or possible adhesions,also total or subtotal and to preserve her ovaries or not,the risk of premature ovarian failure aand the need for HRT.         ENDOMETRIAL ABLATION:also the she has to be decided for no more pregnancies.effective but does not relieve dysmenorrhea.contraction is imoprtant in immediate postprocedure period,this procedure is associated with lower morbidity compared to hysterectomy,but the need for surgery again either to repeat procedure or hysterectomy is still there.

Information about her LMP, cycle length ,duration and regularity is important to know as it points towards ovulatory function.HER fertility wish help to make further treatment options .Severity of symptoms and impact on quality of life ,her social, sexual and physical health should be taken.Which treatment was used as other medical treatment can be offered before going to surgical method.Also information regarding symptoms of comorbidities like irregular cycles,weight gain ,dysmennorrhoea,pelvic pain,pre menstrual symptoms,inter menstrual bleeding,post coital bleeding and pressure symptoms   as it will help to investigate and diagnose the cause whether structural[PALM] or not .Medical conditions and drugs taken e.g.warfarin and heparin can cause abnormal bleeding should be ruled out.Coagulation screening, any one of the following,heavy periods from age of menarche[unusual in this patient] ,history of PPH,surgery related bleeding ,after tooth extraction and 2 or more of 1-2 times bruising and or epistaxis in a month,family histroy of bleeding problem and gum bleeding,so that coagulopathies should be investigated.Sexual histroy andContraception should be asked for possibility of early pregnancy complications.Personal and family history of breast and ovarian cancer and history of diabetes, age of menarche,use of tamoxifen and unopposed use of estrogen asked from her as these are risk factors of endometrial hyperplasia and carcinoma.Abdominal or pelvic surgery ,c section especially classical will limit certain treatment options.History of lethargy ,constipation and weight gain elicit the need of thyroid assessment.
b]physical examination for BMI, anemia and thyroid enlargement.Abdominal examination for palpable uterus or mass.Pelvic examination to assess uterus size,shape,regularity,mobility,adnexal mass and tenderness.Full blood count for anemia.B-HCG to rule out pregnancy.chlamydia swabs as sub clinical infection associated with AUB.Thyroid function tests and test for coagulapathy only if clinically indicated.Pelvic ultrasound for uterine evaluation.Saline infusion sonography and MRI only if inconclusive usg and if available but not routinely.HYSTEROSCOPY to visualise the uterus.Endometrial biopsy indicated as previous inadequate treatment or if history of persistent inter menstrual bleeding, for endometrial hyperplasia or carcinoma although rare in this age but should be excluded.
c]Endometrial ablation should be offered if no wish of fertility.Its of two types first generation and 2nd generation.2nd generation devices should be used for her as no structural and functional abnormality is present.FLUID-FILLEDTHERMAL BALLOON ABLATION,MICROWAVE ENDOMETRIAL ABLATION,FREE FLUID THERMAL ENDOMETRIAL ABLATION,IMPEDENCE CONTROLLED BIPOLAR RADIOFREQUENCY  ABLATION.Choice should be made on availability, individual prefrence and most importantly cost effective.Endometrial thinning required except in thermal balloon.ONLY freefluid ablation is hysteroscopically done ,others are blind procedures so more risk of complications.Simpler and quicker procedure.Less operator  dependent .Short hospital stay as day case procedure,quick recovery and back to work or social activities make satisfactory for woman.She should be informed of potential side effects like crampy  period pain even if no bleeding,vaginal discharge,infection and rarely perforation and bladder or bowel damage.repeat surgery is common due to failure of method or even need for further hysterectomy.less failure rate in this patient as uterus normal sized with no distorted cavity.She should be counselled about use of contraception as post ablation pregnancy may occur.Ablation should be done carefully or even contraindicated if history of classical section or deficient endometrium<8mm.
Hysterectomy is the definitive treatment but not offered solely for HMB.It should be considered only if other options failed, contraindicated or declined by the patient or she request it and doesn't want uterus and fertility or wish amenorroea.hysterectomy has negative impact on sexual feeling,bladder function and fertility .there is also psychological effect.potential side effects are included infection ,intraoperative hemorrhage,injury to bladder or bowel,rarely DVT and very rarely death.Risk of premature ovarian failure even if ovaries are preserved.So there may be need for HRT and add back therapy.Preferable route is vaginal as compare to abdominal ,it depends on decent and mobility of uterus, vaginal shape  and size and history of previous surgery in this patient.Patient should be informed fully and documented and her wishes should be taken into account.

a)History should be taken regarding her last menstrual period,cycles regularity.This can help in ruling out  bleeding due to pregnancy complications.Any associated intermenstrual bleed,dysmenorrhea,dyspareunia,PMS should be enquired as these symptoms can point towards AUB-O or adenomyosis. History regarding the amount of bleed per cycle,it's impact on her quality of life,anemia requiring treatment should be taken as this may help in deciding her management.History of fatigue ,sudden weight gain,constipation should be taken as these may be suggestive of hypothyroidism.A history of contraception should be taken and a sexual history should be taken to rule out any risk factors for STI as subclinical chlamydial infection can cause AUB-E. A drug history shold be taken regarding  intake of gonadal steroids or TCA or antiepilectics.A family history of hereditary nonpolyposis colorectal cancer should be taken as there is 60%risk of endometrial carcinoma associated with this. Family history of bleeding disordes should be taken as well as a personal history of frequent bruising ,gum bleeding and prolonged bleeding after dental work as this can suggest VWD which often presents as AUB.Any risk factor for endometrial cancer should be ruled out like Tamoxifen therapy,unopposed estrogen,PCOD.Her desire for fertility should be asked.    b)She should have a full blood count,it may reveal anemia requiring treatment.If she has symptims of hypothyroidism a thyroid function test should be done.She should have an endocervical swab taken to rule out chlamydial infection and a cervical smear should be done if due.A transabdominal or transvaginal ultrasound should be done as this will help diagnose leiomyomas,adenomyosis,as well as endometrial and endocervical polyp.If the ultrasound is inconclusive an MRI can effectively diagnose adenomyosis as well as the exact site of leiomyomas.If no lesion is found by these investigations she must undergo hysteroscopy.Along with direct visualisation of the cavity this has the added advantage of letting us take a directed biopsy as well as resection of polyps if any at the same time.   c)Surgical options available to her will depend on whether she wants ammenorrhea,whether she is willing to undergo a major operation or wants a minimally invasive surgery.If patient does not agree to a major operation then she should be given the option of endometrial ablation.This procedure has very high patient satisfaction rate although ammenorrhea following this is 20-40%,a 38% chance of reoperation and 10-25% patients may require hysterectomy at the end of 2-3 years.Conception is contraindicated.Nowadays second generation methods are used like thermal balloon ablation and microwave ablation which are less operator dependant and are faster and can be done under Local anesthesia,This ensures quicker recovery of patient.However prepoeratively the patient has to be given Danazol or GnRH analogue and therefore should be councelled regarding the androgenic side effects of the drugs.This method is also associated with complications like bleeding,uterine perforation requiring laparotomy.bowel injury and ideally should be done under hysterscopic guidance. The other surgical option available to her is hysterectomy.This can be done either laparoscopically or by open method .When done laparoscopically although operative time is increased,and there are risks to bowel injury and great vessels injury, peroperative blood loss is less as compared to the open procedure,recovery is quicker with reduced duration of hospital stay therefore making this procedure cost effective.Open hysterctomy when done can be total or subtotal.Subtotal method has the advantage of being quick with less blood loss but following the surgery there may be cyclical bleeding and there is a small risk of stump carcinoma.In total hysterctomy there is increased blood loss ,increased chance of ureteric injury but the ammenorrhea is complete. Discussion should also take place regarding conservation or removal of ovaries.At her age it is prudent to conserve ovaries,unless they are found to be diseased .Then she may require removal of ovaries with HRT and so benefits and risks of HRT should be explained to her.Patient should be given written information to allow her to make an informed decision. 

1)Detailed menstrual history should be taken LMP, regularity of cycle, patteren of cycle, associated pain, ay evidence of intermenstrual bleeding, post coiatal bleeding should be asked. Like ovolatry distrabance has unpredictable ad irregular cycle. While endometrial cause has predictable bleeding, regular cycle. It may also associated with  intermenstrual bleeding and subclinical chlamydial infection. Any pressure symptom , bladder symptom should be asked as it may be because of fibroid uterus.any history of bleeding disorder like bleeding since menarche, post partum bleeding, bleeding during tooth extraction, frequent epistaxis 1-2 episode  per month, or bruising may suggest coagulation disorder. Family history of HNPCC , endometrial malignancy, ovarian malignancy should be asked to rule out rere case of endometrial ca . history should be assessed o the basis of PALMCOIEN classification. Her obstetric history, like mode of delivry and future fertility wishes should be asked. As she is bleeding since long history should be asked to rule out aneamia like fatigue , lethargy palpitation though it is not v  specific. History should be asked to rule out thyroid disorder by asking lethargy , constipation wt gain.any increase of wt gain , hirsutism and irregular bleeding may suggest pcos. Contraceptive history shoul be taken to  rule outBTB. Detail of pev treatment taken like oral treatmen, or LNG IUS, shoud be asked. Any use of tamoxifen should be checked. Quality of life should be assessed.cervical screening should be checked. Pregnancy should be rule out.

2) FBC- to check hb. Thyroid function test if history is indicative of thyroid disorder,

Bhcg  to rule out pregnancy. Swab for chlamadiya though negative result does ot rule out absence of infection but it also ecessary before any instrumentation of cervix..TVUSG to assese utetine shape size any fibroid,any ovarian pathology and d endometrial thickness. Hysteroscopy and endometrial biopsy to asses endometrial cavity as she has 1^st line treatment failure.

3)before start treatment her fertility wish and contraceptive choice is very imp.as in case of endometrial ablation she should be ready for no fertility and  continue to use contraceptive. In case of endometrial ablation 2^nd generation procedure like fuid filled balloon endometrial ablation , free fluid thermal endometrial ablation, microwave endometrial ablation and radiofrequency endometrial ablation should be use.  It can be done as an outpatientprocedure, under LA . more cost effective then first generation procedure. In case of TBEA preprocedure thing is not required.radiofreuancy ablation is v quick procedur , less pt pain  and  better pt satisfaction.

Risk like vaginal disgcarge, painful period need for further surgery is commeon. Rare complication like uterine perforation is also there which need further sugery.

Women should be willing for hysterectomy if reqired and ready to use conteraceptive is prereuist. It is contraindicated if she want pregnancy ,amenorrea, in case of undiagnosed bleeding and suspected malignancy. It should be done on preve classical section scar uterus.

Other option for her is hysterectomy . it  should only be done if women reuest it, want amenorrea, family complete and she does not want more childerenand other treatment  option fail or contraindicated in sev menstrual bleeding.

She should explain risk of hysterectomy like affect on sexuality, fertility. Bowel dysfunction, ovarian failure and menopasul like symptom. Her wish to conserve ovary should be discussed and documented.

Whenever women choose hysterectomy all the route like vaginal, abdominal and laproscopy should be explain. Route of sx depend on size of uterus no of fbroid, associated comorbadity, shape of vagina and expertise available.

Both subtotal or total abdominal hysterectomy should be discussed. Women  wish shoud be considered and documented

a.)    Detailed menstrual history which includes  LMP, length, regularity of cycle,intermenstrual bleeding and post coital bleeding should be asked.Impact of heavy bleeding on the quality of life should be assessed by asking the use of number of pads, passage of clots,  flooding, dysmenorrhoea,time off work due to bleeding,social life disruption and any psychological issues.  Symptoms of anaemia  such as breathlessness,palpitations and fatigue should be asked.Menorrhagia and dysmenorrhoea suggest the diagnosis of fibroids, whereas intermenstrual  and postcoital bleeding suggests polyps,ectropion,sexually transmitted infections and cervical malignancy.Gynaecological history includes surgeries for treatment of any fibroids,polyps and adenomyosis in the past.Obstetric history includes number of pregnancies,mode of delivery ,time of last child birth and any molar pregnancies .Sexual history includes multiple sexual partners ,past history of any sexually transmitted infection , dyspareunia and chlamydia screening.Contraceptive history includes use of contraceptives and future fertility wishes.Use of CuIUDs can cause menorrhagia where as hormonal contraceptives can cause irregular bleeding.History of coagulopathy such as VonWillibrands disease and thyroid dysfunction should be asked.Risk factors for malignancy such as early menarche,history of PCOS,obesity,hypertension,diabetesmellitus, and use of tamoxifen needs to be elicited.Family history of endometrial cancer,colonic cancer and  breast cancer are risk factors for endometrial cancer.

b.)    Investigations include Urine Pregnancy Test to exclude pregnancy.Blood tests such as FBC to diagnose iron deficiency anaemia,thyroid fuction tests to identify thyroid abnormalities and coagulation screen to identify any coagulopathy.Chlamydia screening also recommended to rule out sexually transmitted infections.Transabdominal and transvaginal scanning to diagnose fibroids ,endocervical and endometrial polyps.As TVS  is  not  100%  sensitive and can miss polyps,sonohysteroscopy is a  better alternative if suboptimal scan.MRI is indicated if suspected adenomyosis and also to further characterize leiomyomas.Hysteroscopy is the gold standard investigation to rule out any organicand structural abnormalitiesof the uterus. .Can be done as an outpatient/under GA. Allows polypectomy if needed as well biopsy.

c.)    AUB-E means abnormal uterine bleeding due to endometrial pathology.Surgical management options include endometrial resection/ablation and hysterectomy.

Endometrial resection is less invasive,offers quicker recovery  and associated with less perinatal morbidity.Aim to reduce menstrual bleeding by the ablation of entire thickness of endometrium using electrical,thermal or laser energy.

Doesnot guarantee amenorrhoea and patient selection is vital for successful outcome.Organicand structural abnormalities of the uterus should be ruled out.

Patients should be counselled that they cannot expect amenorrhoea,should have completed their families and willing  to undergo hysterectomy if needed during the procedure in the  event of any perforation or uncontrolled bleeding.Also they should be willing to continue contraception in the longterm as there is still risk of pregnancy.

First generation techniques include transcervical resection of endometrium using a loop diathermy and roller-balloon ablation.Needs visualisation of endometrium using hysteroscope during the procedure .Success depends on the skill and experience of the operator.Preoperative endometrial thinning using GnRH agonists is recommended to get better results and pelvic infection should be ruled out prior to the procedure.Amenorrhoea rates vary  from 20-40% and long term satisfaction rate is 80% with reoperation rate of 38% at 3 yrs.10-25% may request for hysterectomy in the longterm.Complications include electrosurgical burns ,bleeding,perforation and fluid overload.

Second generation techniques are simpler,quicker and more effective than first generation.

Techniques in use in UK includes fluid filled thermal balloons and microwave endometrial ablation.Fluid filled thermal balloons should not be used in women with large/irregular uterine cavity where as microwave ablation can be used in irregular cavities.Also preoperative endometrial thinning not recommended with fluid filled thermal ablation whilst it can be done with microwave ablation.Amenorrhoea rates better and varies from 30-60% and longterm satisfaction rate is 70-80%.Complications include burns,bleeding,endometritis and perforation.

Hysterectomy is the definitive treatment for AUB-E.Indicated  in  women  who wants amenorrhoea and who have completed their families.More invasive , associated with greater postoperative morbidity ,longer hospital stay and hence has cost implications.

Can be abdominal,vaginal or laparoscopic ;subtotal or total.Discuss risks and benefits of conservation/ removal of ovaries.Take account of woman’s wishes and  ensure documentation of consultation.Complications such as bleeding,infection,thromboembolism and anaesthetic risk should be explained in detail while obtaining the consent.Offer HRT if bilateral salphingooophorectomy.

History of current symptoms including, regularity of cycle, nature of bleeding, How much this bleeding disturbs her daily life activities, last menstrual period date, associated symptoms like dysmenorhoea, migraine, breast tenderness,intermenstrual or postcoital bleeding. Past cycle details, age of menarche . Symptoms associated with anemia like easy fatigability, palpitations. History of contraception, Pap smear. medical history regarding thyroid disease symptoms, symptoms of bleeding disorders. History of smoking ,exercise, anorexia, psychological upsets. Drug history like anticoagulants antideppresants. Family history of breast ovarian colorectal cancers, bleeding disorders.past obstetrical history including mod of deliveries, postpartum hemorrhage. Details of current treatment by general practitioner and about her compliance and any sideeffects. and previously if she had any investigations or treatment of same problem. Her wishes for future fertility should also be assessed which will help in decision of further therapy.

Full blood count should be done to assess indirectly amount of blood loss. a urine pregnancy test if history suggestive of irregular bleeding . Radiological assessment of pelvis preferably with transvaginal ultrasonography should be done to rule out structural lesion like leiomyomas,polyps.diagnosis of polyps may need an MRI. Persistent heavy menstrual bleeding not responding to treatment should also be investigated for histological abnormalities of endometrium like hyperplasia or malignant lesions so endometrial biopsy should also be done for her prereferably along with hysteroscopic guidance.

. Surgical options for this patient include endometrial ablation/resection techniques or hysterectomy. Women should be fully informed of both the options by both verbal and written material and help them to give informed consent. Patient preferences about future fertility and retaining the uterus or overies should be taken into consideration.ist option for her should be endometrial ablation techniques preferably 2^nd generation like microwave Endometrial ablation or thermal balloon endometrial ablation. care ful selection of patient is important with severe symptoms no structural or hitological abnormality no evidence of pelvic infection should be there,women should not expect amenorrhea and she should be having small uterus less than 12 cm.(for microwave ablation less than 10 cm).ablation teqniques are more quicker with less morbidity ,less recovery time and cost effective as compared to hysterectomy with significant improvement of hemoglobin levels and quality of life of women..70 to 80 percent patients are satisfied after 2^nd generation endometrial ablation,95 % get back to their  normal routine after the procedure within three weeks, but these teqniques do not gaurentee amenorhoea and patient may need a hysterectomy later on( 11to 25 % need hysterectomy within 3-4 yrs).risks of microwave endometrial ablation are uterine perforation mild secondary hemorrhage ,vaginal cervical or small bowel burns, it requires hysteroscopic visualization of endometrium before the procedure. Thermal balloon endometrial ablation can be used as a day case procedure under locl anesthesia and do not require previsualization of endometrium having risks of endometritis ,perforation ,hemorrhage,urinary tract infections. Ist generation endometrial ablation teqniques( including transcervical endometrial resection by diathermy loop and roller ball endometrial ablation) are more operator dependant need more expertise than 2^nd generation techniques and they require general anesthesia and hysteroscopic visualization during the procedure.long term satisfaction rates are almost 80 %, possible advers effects of first generation techniques include electrosurgical burns, uterine perforation(11-14 /1000), hemorrhage, infection, fluid over load,immediate need of hysterectomy(2-6/1000) and mortality (.26/1000),. Although hysterectomy is the definitive treatment of heavy menstrual bleeding but it should be the last resort as it is a major surgical procedure having its own morbidity and mortality.3.5 % intraoperative complication rate(injury to bowel bladder other viscras, hemorrhage) and 9% postoperative complication rate(hemorrhage, infection, need of another surgery, thromboembolism) and mortality rate is 0.25 per1000. But long term satisfaction of patients is better than endometrial ablation techniques. Mode of hysterectomy and decision of total or subtotal hysterectomy or preservation or removal of overies should be fully discussed with the patient and she should know that even preserved overies will be compromised after hysterectomy. Risk of bladder dysfunction and urinary incontinence after hysterectomy should also be dicussed with the patient. Vaginal hysterectomy is preffered if conditions met and expertise available or 2^nd line is laparoscopic hysterectomy having more risk of bladder and ureteric injuries and need expertise, if laparoscopic hysterectomy not possible then offer abdominal hysterectomy. Healthy ovaries’ should not be removed unless patient wishes for it or family history of ovarian breast or colorectal cancer for which patient is genetically evaluated.

Dear Paul,

Kindly check that dr priyadarshini's answer ,that is after mine, is corrected under my name.Please correct my answer.

Thanking you

Farzana s

I will start by asking her about the effect of the heavy bleeding on her quality of life.Then I will ask her about her menstrual history-herage at menarche,duration of heavy bleeding,last menstrual period, regularity of cycles,associated dysmenorrhoea.History of contraception should be taken.History of epistaxis,easy bruising,heavy cyles since menarche indicates a bleeding disorder.History of thyroid disease,diabetes,liver disease,all which can cause menstrual disturbance.Her desire for future fertility should be assessed.History of any pressure symptoms like heaviness in lower abdomen,frequency of bowel and micturition should be taken.She should be asked about the medications she has used for her menorrhagia and compliance.  previous history of operations should be taken.Her mode of deliveries and age of last chald should be asked.A history of postcoital and instermenstrual bleeding should also be asked.History of last cervical smear should be taken.She should be asked about any persistent foul smelling vaginal discharge associated with lower abdominal pain to assess for sexually transmitted diseases.Family history of any gynaecological cancers should be taken.

B.A complete  blood count should be done to check for anaemia and low platelet count to rule out a bleeding disorder.If she has postcoital or intermenstrual bleeding ,cervical smear should be taken if she didn’t have one as per her schedule.A transvaginal ultrasound should be done to rule  endometrial polyps or fibroids if the history is suggestive of one.As there is failure of medical treatment Hysteroscopy and endometrial biopsy should be done to look for submucous fibroids,endometrial polyps,endometrial hyperplasia/cancer.Outpatinet hysteroscopy is another option for endometrial biopsy but with hysteroscopy submucous fibroid resection and polypectomy can be done at the same sitting.Thyroid function tests and coagulation factors should be assessed If history is suggestive of thyroid disease or bleeding disorders.

C.The various surgical options available includes Endometrial ablation,Uterine artery embolisation,Hysteroscopic resection of fibroids and polyps,Myomectomy and Hysterectomy.

Endometrial ablation can be done in woman who are no longer desirous of fertility,with no endometrial pathology (fibroids less than 3 cm if present),and with uterine size less than 10cm.It can be performed as a day case procedure and under local anaesthesia.There is 70-90% less bleeding ,40 amenorrhoea,30% need for further treatment at the end of 12months.The woman should be advised to use contraception as it does not confer complete contraception.Side effects include abdominal cramps,light bleeding for 3-4 weeks,infection,uterine perforation etc.

Uterine artery embolisation (UAE )is another option where the uterine arteries are embolised via the femoral arteries.It is done by an Interventional Radiologist and is not easily available.if the woman wants to retain her fertility and has large fibroids distorting the endometrial cavity.It can also be done as a day case and under local anaesthesia+/- sedation.There is 40-75% reduction in the size of fibroids and 60-95% symptomatic relief with UAE.It is associated with 1% risk of premature ovarian failure if there is inadvertent embolisation of ovarian arteries.

Hyseterescopic resection of endometrial polyps or submucous fibroids if they have been diagnosed during the investigations.Hysteroscopy can be done under local or general anaesthesia but can be done as a day case.There is a risk of uterine perforation,excessive bleeding or volume overload with the procedure.

Myomectomy is an option if  fibroids are a cause of her menorrhagia and she is wants to retain her fertility.Is is under regional or general anaestheisa.Preoperative GnRH analogues can be given to shrink the size of the fibroids and minimize blood loss during surgery.There is a 5-11% risk of recurrence of the fibroids and need 17% risk of need for further treatment.Myomectomy can be done either as an open procedure or by laparoscopy .There is a need for future delivery by cesarean section if the uterine cavity is entered during the procedure.

Hysterectomy can be done as a last resort when all the above options fail or are contraindicated or if the woman wishes for it or is not desirous of future fertility.Vaginal approach is the preferred route if possible or an abdominal approach should be adopted.It is done under regional or general anaesthesia.The woman should be counseled about a slight  risk of menopause even when the ovaries are retained.She should also be counseled about other risks of the procedure like heamorrhage 15/1000,need for blood transfusion,injury to bladder,bowel,uereters 7/1000,return to theatre,infection  2/1000 ,thromboembolism 4/1000etc.Risks of anaesthesia should also be explained along with postoperative management (like pain relief,mobilization,indwelling urinary catheter) while in the hospital.

I will give her relevant information leaflets to further assist her. 

KRA

 A.  I would take a menstrual history enquiring about her last menstrual period, regularity and frequency of her cycles.  I would make a subjective assessment of blood loss enquiring about sanitary protection usage, flooding and clots and enquire about he impact of her quality of life.  I would find out about associated symptoms like dyspareunia and dysmenorrhoea which may suggest pelvic pathology or infection.  I would find out about her fertility intentions whether she has completed her family or not because some further treatment methods impact on fertility.  I would enquire about symptoms of fatigue, shortness of breath, tiredness and palpitations which may suggest anaemia.  I would take a sexual history enquiring sensitively about number of sexual partners and any recent change of sexual partners which may put her at risk of pelvic infection.

B.  I would arrange for a full blood count to exclude anaemia.  I would arrange for an ultrasound scan of the pelvis to identify structural abnormalities like fibroids and polyps and also measure endometrial thickness. 

C.  I would consider endometrial ablation techniques which destroy the lining of the womb and reduce menstrual bleeding.  They are less invasive than hysterectomy and are performed as day case procedures.  First generation procedures include roller ball and transcervical resection of the endometrium.  They are more operator dependant and complications include uterine perforation, haemorrhage and fluid overload.  They are recommended in women with structural abnormalities like fibroids and contraception is recommended following procedure.  Second generation ablative procedures include balloon  ablation and microwave.  They are less operator dependent used in women with no structural or histological abnormalities.  Complications include perforation, haemorrhage and endometritis.  Hysteroscopic myomectomy can be used with fibroids >3cm in diameter.  It is recommended in women who want to retain their uterus and fertility.  Complications include perforation, need for additional surgery and infection.  Uterine artery embolisation can be used where there are fibroids >3cm in diameter and other significant symptoms like pain and pressure.  It involves the blocking of blood supply to the fibroid and this causes them to shrink.  It is recommended for women who want to retain their uterus and fertility is potentially retained.  Complications include perforation, haemorrhage, infection and adhesions.  Hysterectomy is a definitive treatment where she wants to be amenorrhoeic and family is complete.  It may be by the abdominal or vaginal route based on individual assessment.  First line would be vaginal.  Consideration would be given to subtotal hysterectomy which is associated with reduced operating time and reduced incidents of vault prolapse but need for continuing cervical smears.  Laparoscopic vaginal hysterectomy is considered in morbidly obese.  The complications of hysterectomy include haemorrhage, urinary tract and bowel dysfunction and infection.

Please Dr Paul : This is not my answer that you have corrected ,.Actually my answer is not corrected.           Please correct my answer.

History of current symptoms including, regularity of cycle, nature of bleeding, How much this bleeding disturbs her daily life activities, last menstrual period date, associated symptoms like dysmenorhoea, migraine, breast tenderness,intermenstrual or postcoital bleeding (1) . Past cycle details, age of menarche . Symptoms associated with anemia like easy fatigability, palpitations  (1). History of contraception, Pap smear. medical history regarding thyroid disease symptoms, symptoms of bleeding disorders. History of smoking ,exercise, anorexia, psychological upsets. ? relevance Drug history like anticoagulants antideppresants. Family history of breast ovarian colorectal cancers why?, bleeding disorders.past obstetrical history including mod of deliveries, postpartum hemorrhage why? there is no discussion. Details of current treatment by general practitioner and about her compliance and any sideeffects. and previously if she had any investigations or treatment of same problem. Her wishes for future fertility (1) should also be assessed which will help in decision of further therapy.

Full blood count should be done to assess indirectly amount of blood loss. a urine pregnancy test (1) if history suggestive of irregular bleeding . Radiological assessment of pelvis preferably with transvaginal ultrasonography should be done to rule out structural lesion like leiomyomas,polyps (1).diagnosis of polyps may need an MRI. Persistent heavy menstrual bleeding not responding to treatment should also be investigated for histological abnormalities of endometrium like hyperplasia or malignant lesions so endometrial biopsy should also be done for her prereferably along with hysteroscopic guidance why is it just preferably? Is there any other option?.

. Surgical options for this patient include endometrial ablation/resection techniques or hysterectomy. Women should be fully informed of both the options by both verbal and written material and help them to give informed consent. You were asked to critically evaluate Patient preferences about future fertility and retaining the uterus or overies should be taken into consideration.ist option for her should be endometrial ablation techniques preferably 2^nd generation like microwave Endometrial ablation or thermal balloon endometrial ablation. care ful selection of patient is important with severe symptoms no structural or hitological abnormality no evidence of pelvic infection should be there she has AUB-E,women should not expect amenorrhea what % have amenorrhoea? and she should be having small uterus less than 12 cm.(for microwave ablation less than 10 cm).ablation teqniques are more quicker with less morbidity ,less recovery time and cost effective as compared to hysterectomy (1) with significant improvement of hemoglobin levels and quality of life of women..70 to 80 percent patients are satisfied after 2^nd generation endometrial ablation,95 % get back to their  normal routine after the procedure within three weeks, but these teqniques do not gaurentee amenorhoea and patient may need a hysterectomy later on( 11to 25 % need hysterectomy within 3-4 yrs) (1).risks of microwave endometrial ablation are uterine perforation mild secondary hemorrhage ,vaginal cervical or small bowel burns, it requires hysteroscopic visualization of endometrium before the procedure (1). Thermal balloon endometrial ablation can be used as a day case procedure under locl anesthesia and do not require previsualization of endometrium having risks of endometritis ,perforation ,hemorrhage,urinary tract infections (1). Ist generation endometrial ablation teqniques( including transcervical endometrial resection by diathermy loop and roller ball endometrial ablation) are more operator dependant need more expertise than 2^nd generation techniques and they require general anesthesia and hysteroscopic visualization during the procedure (1).long term satisfaction rates are almost 80 %, possible advers effects of first generation techniques include electrosurgical burns, uterine perforation(11-14 /1000), hemorrhage, infection, fluid over load,immediate need of hysterectomy(2-6/1000) and mortality (.26/1000) (1),. Although hysterectomy is the definitive treatment of heavy menstrual bleeding but it should be the last resort what if she requests it because she wants amenorrhoea? as it is a major surgical procedure having its own morbidity and mortality.3.5 % intraoperative complication rate(injury to bowel bladder other viscras, hemorrhage) and 9% postoperative complication rate(hemorrhage, infection, need of another surgery, thromboembolism) and mortality rate is 0.25 per1000 (1). But long term satisfaction of patients is better than endometrial ablation techniques. Mode of hysterectomy and decision of total or subtotal hysterectomy or preservation or removal of overies should be fully discussed with the patient and she should know that even preserved overies will be compromised after hysterectomy what will you recommend?. Risk of bladder dysfunction and urinary incontinence what is the risk?? after hysterectomy should also be dicussed with the patient. Vaginal hysterectomy is preffered if conditions met which conditions?and expertise available or 2^nd line is laparoscopic hysterectomy having more risk of bladder and ureteric injuries and need expertise, if laparoscopic hysterectomy not possible then offer abdominal hysterectomy ? laparoscopic. Healthy ovaries’ should not be removed unless patient wishes (1) for it or family history of ovarian breast or colorectal cancer for which patient is genetically evaluated.

I will start by asking her about the effect of the heavy bleeding on her quality of life.Then I will ask her about her menstrual history-herage at menarche,duration of heavy bleeding,last menstrual period, regularity of cycles,associated dysmenorrhoea (1).History of contraception should be taken.History of epistaxis,easy bruising,heavy cyles since menarche indicates a bleeding disorder.History of thyroid disease,diabetes,liver disease,all which can cause menstrual disturbance.Her desire for future fertility should be assessed (1).History of any pressure symptoms like heaviness in lower abdomen,frequency of bowel and micturition should be taken.She should be asked about the medications she has used for her menorrhagia and compliance.  previous history of operations should be taken.Her mode of deliveries and age of last chald should be asked why?.A history of postcoital and instermenstrual bleeding should also be asked.History of last cervical smear should be taken (1).She should be asked about any persistent foul smelling vaginal discharge associated with lower abdominal pain to assess for sexually transmitted diseases full sexual hx.Family history of any gynaecological cancers should be taken ? cervical cancer?.

B.A complete  blood count should be done to check for anaemia and low platelet count to rule out a bleeding disorder.If she has postcoital or intermenstrual bleeding ,cervical smear should be taken if she didn’t have one as per her schedule pregnancy test.A transvaginal ultrasound (1) should be done to rule  endometrial polyps or fibroids if the history is suggestive of one.As there is failure of medical treatment Hysteroscopy and endometrial biopsy (1) should be done to look for submucous fibroids,endometrial polyps,endometrial hyperplasia/cancer.Outpatinet hysteroscopy is another option for endometrial biopsy but with hysteroscopy submucous fibroid resection and polypectomy can be done at the same sitting.Thyroid function tests and coagulation factors should be assessed If history is suggestive of thyroid disease or bleeding disorders.

C.The various surgical options available includes Endometrial ablation,Uterine artery embolisation,Hysteroscopic resection of fibroids and polyps,Myomectomy and Hysterectomy. Not for AUB-E

Endometrial ablation can be done in woman who are no longer desirous of fertility,with no endometrial pathology (fibroids less than 3 cm if present),and with uterine size less than 10cm.It can be performed as a day case procedure and under local anaesthesia.There is 70-90% less bleeding ,40 amenorrhoea,30% need for further treatment at the end of 12months (1).The woman should be advised to use contraception as it does not confer complete contraception not a contraceptive.Side effects include abdominal cramps,light bleeding for 3-4 weeks,infection,uterine perforationetc. what else???

Uterine artery embolisation (UAE ) suggests you did not read the question / do not know what AUB-E means is another option where the uterine arteries are embolised via the femoral arteries.It is done by an Interventional Radiologist and is not easily available.if the woman wants to retain her fertility and has large fibroids distorting the endometrial cavity.It can also be done as a day case and under local anaesthesia+/- sedation.There is 40-75% reduction in the size of fibroids and 60-95% symptomatic relief with UAE.It is associated with 1% risk of premature ovarian failure if there is inadvertent embolisation of ovarian arteries.

Hyseterescopic resection of endometrial polyps or submucous fibroids if they have been diagnosed during the investigations.Hysteroscopy can be done under local or general anaesthesia but can be done as a day case.There is a risk of uterine perforation,excessive bleeding or volume overload with the procedure.

Myomectomy is an option if  fibroids are a cause of her menorrhagia and she is wants to retain her fertility.Is is under regional or general anaestheisa.Preoperative GnRH analogues can be given to shrink the size of the fibroids and minimize blood loss during surgery.There is a 5-11% risk of recurrence of the fibroids and need 17% risk of need for further treatment.Myomectomy can be done either as an open procedure or by laparoscopy .There is a need for future delivery by cesarean section if the uterine cavity is entered during the procedure.

Hysterectomy can be done as a last resort when all the above options fail or are contraindicated or if the woman wishes for it or is not desirous of future fertility.Vaginal approach is the preferred route why?? if possible or an abdominal approach should be adopted.It is done under regional or general anaesthesia.The woman should be counseled about a slight  risk of menopause even when the ovaries are retained ? meaning?? All women eventually become menopausal.She should also be counseled about other risks of the procedure like heamorrhage 15/1000,need for blood transfusion,injury to bladder,bowel,uereters 7/1000,return to theatre,infection  2/1000 ,thromboembolism 4/1000etc.??? you are not answering the question. You were not asked about what the woman should be told Risks of anaesthesia should also be explained along with postoperative management (like pain relief,mobilization,indwelling urinary catheter) while in the hospital.

I will give her relevant information leaflets to further assist her. Critically evaluate – how does giving her an information leaflet critically evaluate the options?

KRA

 A.  I would take a menstrual history enquiring about her last menstrual period, regularity and frequency of her cycles.  I would make a subjective assessment of blood loss enquiring about sanitary protection usage, flooding and clots and enquire about he impact of her quality of life (1).  I would find out about associated symptoms like dyspareunia and dysmenorrhoea which may suggest pelvic pathology or infection.  I would find out about her fertility intentions whether she has completed her family or not because some further treatment methods impact on fertility.  I would enquire about symptoms of fatigue, shortness of breath, tiredness and palpitations which may suggest anaemia (1).  I would take a sexual history enquiring sensitively about number of sexual partners and any recent change of sexual partners which may put her at risk of pelvic infection (1) contraception, risk factors for endometrial cancer.

B.  I would arrange for a full blood count to exclude anaemia.  I would arrange for an ultrasound scan of the pelvis to identify structural abnormalities like fibroids and polyps and also measure endometrial thickness (1) pregnancy test, hysteroscopy + endometrial biopsy. 

C.  I would consider endometrial ablation techniques which destroy the lining of the womb and reduce menstrual bleeding.  They are less invasive than hysterectomy and are performed as day case procedures.  First generation procedures include roller ball and transcervical resection of the endometrium.  They are more operator dependant (1) and complications include uterine perforation, haemorrhage and fluid overload (1).  They are recommended in women with structural abnormalities like fibroids has she got fibroids? and contraception is recommended following procedure.  Second generation ablative procedures include balloon  ablation and microwave.  They are less operator dependent used in women with no structural or histological abnormalities.  Complications include perforation, haemorrhage and endometritis (1).  Hysteroscopic myomectomy read the question – AUB-E can be used with fibroids >3cm in diameter.  It is recommended in women who want to retain their uterus and fertility.  Complications include perforation, need for additional surgery and infection.  Uterine artery embolisation either you have not read the question or you do not understand what AUB-E means can be used where there are fibroids >3cm in diameter and other significant symptoms like pain and pressure.  It involves the blocking of blood supply to the fibroid and this causes them to shrink.  It is recommended for women who want to retain their uterus and fertility is potentially retained.  Complications include perforation, haemorrhage, infection and adhesions.  Hysterectomy is a definitive treatment where she wants to be amenorrhoeic (1) and family is complete.  It may be by the abdominal or vaginal route based on individual assessment or laparoscopic.  First line would be vaginal why?.  Consideration would be given to subtotal hysterectomy which is associated with reduced operating time and reduced incidents of vault prolapse but need for continuing cervical smears (1) can you do this vaginally?.  Laparoscopic vaginal hysterectomy is considered in morbidly obese. Why do you have to be morbidly obese to get a less invasive operation like LAVH or lap total / sub-total hyst??  The complications of hysterectomy include haemorrhage, urinary tract and bowel dysfunction and infection.

Detailed history is important which including any history of increased weight ( Obesity ) or anovulation cycle such as poly cystic ovarian syndrome ( PCOS ) because of unopposed estrogen by progesterone on endometrium. Any use of HRT without progesterone should be asked. Drug history such as Tamoxifen should be obtained because it can cause endometrial hyperplasia and cancer after a period of time. Medical history such as DM or hypertension should be asked because they can coexist with endometrial hyperplasia. Hirsutism and speed of hair growth should be asked and any surgical operation for any adnexal mass or ovarian tumor was happened . Family history for breast , ovarian,colorectal cancers in genetic cases such as Heredity non polepose colorectal cancer ( HNPCC) .

The investigation should include FBC for anemia from heavy bleeding.

Abdominal ultrasound for the size of uterus and adnexal mass, and trans vaginal ultrasound to measure the thickness of endometrium.

Endometrial biopsy by Pipple tube can be done for histology.

Office Hysteroscopy and biopsy is useful to exclude any hyperplasia or malignancy.

The first surgical option is endometrial ablation by second generation hysteroscopy of ablation such as microwaves, heat balloon which are easy to use and less complications and can do under local anesthesia in office. On the other hand, it does not eradicate all the endometrium and so high risk of recurrence bleeding and needs less training.

Endometrial resection is another option in which eradicate the endometrium by loop and coagulation with hysteroscopy but it needs general anesthesia, with risk of overloading fluids from the media (Glycin ) and hyponatremia and may cause pulmonary edema and death.   This method does not offer for patients want more children because it cause intrauterine adhesions and can cause placenta praevia or accrete in next pregnancy.

The other surgical options are hysterectomy abdominally or vaginally.

Abdominal hysterectomy is more satisfactory than ablation with no recurrence but has more complications such as general anesthesia , risk of bowel bladder or ureter injuries, hemorrhage, wound infection and hernia.

Vaginal hysterectomy has less complications than abdominal one with more risk ureter injuries .

Laparoscopic Assisted Vaginal Hysteroctomy ( LAVH )is useful with good satisfaction but it needs special equipments , expertise and practice, with high risk of ureter injuries from coagulation .

A)    I would ask about regularity of her periods and amount bleeding, how long the bleeding lasts for, if there is any clots, how frequently is she changing her pads and if it is affecting her life. I would ask about LMP, parity (mode of delivery and any complications) and if she is using any contraception. I would also enquiry about her smear history and if there was any abnormal smears in the past. I would ask about dyspareunia, postcoital bleeding and intermenstrual bleeding. Does she have any thyroid problems or any bleeding disorders? Is she taking any medication that could be causing bleeding?

B)    I would order a full blood count to make sure she is not anaemic. I would check her thyroid function tests, if she is symptomatic for thyroid disorders and I would also check her clotting factors, if there is a family history of bleeding disorders. I would order a pelvic ultrasound to rule out fibroids or polyps.

C)First surgical option would a dilation and curettage. A second option could be to perform a curettage and uterine balloon therapy but this would depend on whether she wishes have more children. The last option would be a hysterectomy but the risk of injury to bladder, bowel, blood vessels and the anaesthetic used should be stressed and also the irreversibility of the procedure and risk of needing a blood transfusion.