Management of heavy menstrual bleeding in general practice

Radiofrequency endometrial ablation for treating heavy menstrual bleeding in women with chronic renal failure

OBJECTIVE

The study objective was to retrospectively evaluate the efficacy and safety of radiofrequency endometrial ablation in treating heavy menstrual bleeding (HMB) in women with chronic renal failure (CRF).

METHOD

Fifty-eight patients with CRF undergoing radiofrequency endometrial ablation in our hospital between January 2013 and July 2017 and for whom complete follow-up data were available were included. Outcome measures included amenorrhea, treatment failure and operative complications.

RESULTS

The mean patient age was 41.4 ± 7.7 years, the mean preoperative hemoglobin level was 69.6 ± 19.3 g/dL, the mean preoperative serum creatinine level was 879.1 ± 415.4 µmol/L, and the mean urea level was 18.2 ± 7.1 mmol/L. The mean treatment time for radiofrequency endometrial ablation was 61.7 ± 18.8 s. The median volume of estimated blood loss during the procedure was 10 mL (a range of 2-50 mL). On average, the study subjects were monitored for 24.4 months (a range of 6-60 months). The average amenorrhea rate was 89.7%. Only 2 (3.4%) patients required additional gynecologic surgery after endometrial ablation. Intra- and postoperative complications were not observed.

CONCLUSION

Radiofrequency endometrial ablation was demonstrated to be safe and effective for the treatment of HMB in women with CRF.

Antifibrinolytics for heavy menstrual bleeding

BACKGROUND

Heavy menstrual bleeding (HMB) is an important physical and social problem for women. Oral treatment for HMB includes antifibrinolytic drugs, which are designed to reduce bleeding by inhibiting clot-dissolving enzymes in the endometrium.Historically, there has been some concern that using the antifibrinolytic tranexamic acid (TXA) for HMB may increase the risk of venous thromboembolic disease. This is an umbrella term for deep venous thrombosis (blood clots in the blood vessels in the legs) and pulmonary emboli (blood clots in the blood vessels in the lungs).

OBJECTIVES

To determine the effectiveness and safety of antifibrinolytic medications as a treatment for heavy menstrual bleeding.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO and two trials registers in November 2017, together with reference checking and contact with study authors and experts in the field.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing antifibrinolytic agents versus placebo, no treatment or other medical treatment in women of reproductive age with HMB. Twelve studies utilised TXA and one utilised a prodrug of TXA (Kabi).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. The primary review outcomes were menstrual blood loss (MBL), improvement in HMB, and thromboembolic events.

MAIN RESULTS

We included 13 RCTs (1312 participants analysed). The evidence was very low to moderate quality: the main limitations were risk of bias (associated with lack of blinding, and poor reporting of study methods), imprecision and inconsistency.Antifibrinolytics (TXA or Kabi) versus no treatment or placeboWhen compared with a placebo, antifibrinolytics were associated with reduced mean blood loss (MD -53.20 mL per cycle, 95% CI -62.70 to -43.70; I² = 8%; 4 RCTs, participants = 565; moderate-quality evidence) and higher rates of improvement (RR 3.34, 95% CI 1.84 to 6.09; 3 RCTS, participants = 271; moderate-quality evidence). This suggests that if 11% of women improve without treatment, 43% to 63% of women taking antifibrinolytics will do so. There was no clear evidence of a difference between the groups in adverse events (RR 1.05, 95% CI 0.93 to 1.18; 1 RCT, participants = 297; low-quality evidence). Only one thromboembolic event occurred in the two studies that reported this outcome.TXA versus progestogensThere was no clear evidence of a difference between the groups in mean blood loss measured using the Pictorial Blood Assessment Chart (PBAC) (MD -12.22 points per cycle, 95% CI -30.8 to 6.36; I² = 0%; 3 RCTs, participants = 312; very low quality evidence), but TXA was associated with a higher likelihood of improvement (RR 1.54, 95% CI 1.31 to 1.80; I² = 32%; 5 RCTs, participants = 422; low-quality evidence). This suggests that if 46% of women improve with progestogens, 61% to 83% of women will do so with TXA.Adverse events were less common in the TXA group (RR 0.66, 95% CI 0.46 to 0.94; I² = 28%; 4 RCTs, participants = 349; low-quality evidence). No thromboembolic events were reported in any group.TXA versus non-steroidal anti-inflammatory drugs (NSAIDs)TXA was associated with reduced mean blood loss (MD -73.00 mL per cycle, 95% CI -123.35 to -22.65; 1 RCT, participants = 49; low-quality evidence) and higher likelihood of improvement (RR 1.43, 95% CI 1.18 to 1.74; 1² = 0%; 2 RCTs, participants = 161; low-quality evidence). This suggests that if 61% of women improve with NSAIDs, 71% to 100% of women will do so with TXA. Adverse events were uncommon and no comparative data were available. No thromboembolic events were reported.TXA versus ethamsylateTXA was associated with reduced mean blood loss (MD 100 mL per cycle, 95% CI -141.82 to -58.18; 1 RCT, participants = 53; low-quality evidence), but there was insufficient evidence to determine whether the groups differed in rates of improvement (RR 1.56, 95% CI 0.95 to 2.55; 1 RCT, participants = 53; very low quality evidence) or withdrawal due to adverse events (RR 0.78, 95% CI 0.19 to 3.15; 1 RCT, participants = 53; very low quality evidence).TXA versus herbal medicines (Safoof Habis and Punica granatum)TXA was associated with a reduced mean PBAC score after three months' treatment (MD -23.90 pts per cycle, 95% CI -31.92 to -15.88; I² = 0%; 2 RCTs, participants = 121; low-quality evidence). No data were available for rates of improvement. TXA was associated with a reduced mean PBAC score three months after the end of the treatment phase (MD -10.40 points per cycle, 95% CI -19.20 to -1.60; I² not applicable; 1 RCT, participants = 84; very low quality evidence). There was insufficient evidence to determine whether the groups differed in rates of adverse events (RR 2.25, 95% CI 0.74 to 6.80; 1 RCT, participants = 94; very low quality evidence). No thromboembolic events were reported.TXA versus levonorgestrel intrauterine system (LIUS)TXA was associated with a higher median PBAC score than TXA (median difference 125.5 points; 1 RCT, participants = 42; very low quality evidence) and a lower likelihood of improvement (RR 0.43, 95% CI 0.24 to 0.77; 1 RCT, participants = 42; very low quality evidence). This suggests that if 85% of women improve with LIUS, 20% to 65% of women will do so with TXA. There was insufficient evidence to determine whether the groups differed in rates of adverse events (RR 0.83, 95% CI 0.25 to 2.80; 1 RCT, participants = 42; very low quality evidence). No thromboembolic events were reported.

AUTHORS' CONCLUSIONS

Antifibrinolytic treatment (such as TXA) appears effective for treating HMB compared to placebo, NSAIDs, oral luteal progestogens, ethamsylate, or herbal remedies, but may be less effective than LIUS. There were too few data for most comparisons to determine whether antifibrinolytics were associated with increased risk of adverse events, and most studies did not specifically include thromboembolism as an outcome.

Economic Evaluation of Global Endometrial Ablation Versus Inpatient and Outpatient Hysterectomy for Treatment of Abnormal Uterine Bleeding: US Commercial and Medicaid Payer Perspectives

Every year, abnormal uterine bleeding (AUB) exacts a heavy toll on women's health and leads to high costs for the US health care system. The literature shows that endometrial ablation results in fewer complications, shorter recovery and lower costs than more commonly performed hysterectomy procedures. The objective of this study was to model clinical-economic outcomes, budget impact, and cost-effectiveness of global endometrial ablation (GEA) versus outpatient hysterectomy (OPH) and inpatient hysterectomy (IPH) procedures. A decision tree, state-transition (semi-Markov) economic model was developed to simulate 3 hypothetical cohorts of women who received surgical treatment for AUB (GEA, OPH, and IPH) over 1, 2, and 3 years to evaluate clinical and economic outcomes for GEA vs. OPH and GEA vs. IPH. Two versions of the model were created to reflect both commercial health care payer and US Medicaid perspectives, and analyses were conducted for both payer types. Total health care costs in the first year after GEA were substantially lower compared with those for IPH and OPH. Budget impact analysis results showed that increasing GEA utilization yields total annual cost savings of about $906,000 for a million-member commercial health plan and about $152,000 in cost savings for a typical-sized state Medicaid plan with 1.4 million members. Cost-effectiveness analysis results for both perspectives showed GEA as economically dominant (conferring greater benefit at lower cost) over both OPH and IPH in the 1-year commercial scenario. This study demonstrates that, for some patients, GEA may prove to be a safe, uterus-sparing, cost-effective alternative to OPH and IPH for the surgical treatment of AUB.

Radiofrequency-induced endometrial ablation for the treatment of postpartum hemorrhage after vaginal delivery: Case report

RATIONALE

Postpartum hemorrhage is a common complication and difficult problem in obstetrics. Radiofrequency-induced endometrial ablation (RFIEA) widely used in abnormal uterine bleeding and achieved good effects. This article will investigate the effect of RFIEA for treatment of postpartum hemorrhage.

PATIENTS CONCERNS

A 26-year-old healthy full-term parturient woman presented with postpartum hemorrhage after vaginal delivery for 11 hours, who was ready to emergency surgery (hysterectomy) 7 hours after inserting an intrauterine balloon into uterine cavity.

DIAGNOSES

Blood loss after vaginal delivery was more than 500 mL during 11 hours in the full-term parturient woman.

INTERVENTION

We applied RFIEA to treatment of postpartum hemorrhage. With the patient in dorsal lithotomy position, we advanced the disposable device according to the instruction and operated the Novasure system in semi-automatic mode.

OUTCOMES

There was no obvious endometrial bleeding found with hysteroscopy at the end of surgery. No complications (such as thermal injury to adjacent tissue, uterine perforation, bowel perforation) were observed.

LESSONS

It is safe and effective to treat postpartum hemorrhage after vaginal delivery using RFIEA.

Disability benefits as an incentive for hysterectomy: Uterine fibroid patients in Taiwan

Worker compensation insurance in Taiwan ensures that a woman under the age of 45 years who has her uterus removed can receive disability compensation benefits. The present study investigated whether such a compensation policy was related to a woman's inclination to have a hysterectomy. We extracted the records of 16,030 women diagnosed with uterine fibroids (UF) between 2000 and 2010 from the Longitudinal Taiwan Health Insurance Database. Each younger and older age group had a significantly lower hysterectomy rate compared to that of the 44-year-old age group. Moreover, significantly more patients with lower monthly wages had had hysterectomies than those with higher monthly wages. Policy makers should be aware that worker compensation regulations in Taiwan might encourage women with economic need to undergo hysterectomy surgery when approaching the age of 45 years.

Cost-Effectiveness of Global Endometrial Ablation vs. Hysterectomy for Treatment of Abnormal Uterine Bleeding: US Commercial and Medicaid Payer Perspectives

Cost-effectiveness modeling studies of global endometrial ablation (GEA) for treatment of abnormal uterine bleeding (AUB) from a US perspective are lacking. The objective of this study was to model the cost-effectiveness of GEA vs. hysterectomy for treatment of AUB in the United States from both commercial and Medicaid payer perspectives. The study team developed a 1-, 3-, and 5-year semi-Markov decision-analytic model to simulate 2 hypothetical patient cohorts of women with AUB-1 treated with GEA and the other with hysterectomy. Clinical and economic data (including treatment patterns, health care resource utilization, direct costs, and productivity costs) came from analyses of commercial and Medicaid claims databases. Analysis results show that cost savings with simultaneous reduction in treatment complications and fewer days lost from work are achieved with GEA versus hysterectomy over almost all time horizons and under both the commercial payer and Medicaid perspectives. Cost-effectiveness metrics also favor GEA over hysterectomy from both the commercial payer and Medicaid payer perspectives-evidence strongly supporting the clinical-economic value about GEA versus hysterectomy. Results will interest clinicians, health care payers, and self-insured employers striving for cost-effective AUB treatments.

Radiofrequency endometrial ablation for the treatment of heavy menstrual bleeding among women at high surgical risk

OBJECTIVE

To evaluate quality of life (QoL) after radiofrequency endometrial ablation (RFEA) for heavy menstrual bleeding among women at high surgical risk.

METHODS

An observational study was undertaken among women aged at least 18 years who underwent RFEA at Hanover Medical School, Germany, between June 2010 and November 2012. A validated menorrhagia outcomes questionnaire (MOQ) was used to evaluate QoL and global outcomes among patients at high risk and low risk of complications after major surgery. The high-risk group included women with anemia, coagulopathy, anticoagulation, thromboembolism, transplantation, malignancy, severe cardiovascular or pulmonary disease, and obesity.

RESULTS

Overall, 235 women underwent RFEA during the study period. Median follow-up was 13 months (range 3-30). Questionnaire responses were received from 202 (86.0%) women, including 132 (65.3%) high-risk patients. The MOQ total outcome (mean difference 2.0; P = 0.166) and QoL/satisfaction (mean difference 0.8; P = 0.601) scores were similar in the two groups. Success (i.e. symptom relief and no further surgery) was recorded for 119 (90.2%) patients in the high-risk group and 67 (95.7%) patients in the low-risk group (P = 0.155).

CONCLUSION

RFEA improved QoL and achieved a high rate of satisfaction for both high- and low-risk patients. RFEA offers a less invasive alternative to hysterectomy and its associated perioperative risks, particularly among high-risk patients.

Cost effectiveness of endometrial ablation with the NovaSure(®) system versus other global ablation modalities and hysterectomy for treatment of abnormal uterine bleeding: US commercial and Medicaid payer perspectives

OBJECTIVES

Abnormal uterine bleeding (AUB) interferes with physical, emotional, and social well-being, impacting the quality of life of more than 10 million women in the USA. Hysterectomy, the most common surgical treatment of AUB, has significant morbidity, low mortality, long recovery, and high associated health care costs. Global endometrial ablation (GEA) provides a surgical alternative with reduced morbidity, cost, and recovery time. The NovaSure(®) system utilizes unique radiofrequency impedance-based GEA technology. This study evaluated cost effectiveness of AUB treatment with NovaSure ablation versus other GEA modalities and versus hysterectomy from the US commercial and Medicaid payer perspectives.

METHODS

A health state transition (semi-Markov) model was developed using epidemiologic, clinical, and economic data from commercial and Medicaid claims database analyses, supplemented by published literature. Three hypothetical cohorts of women receiving AUB interventions were simulated over 1-, 3-, and 5-year horizons to evaluate clinical and economic outcomes for NovaSure, other GEA modalities, and hysterectomy.

RESULTS

Model analyses show lower costs for NovaSure-treated patients than for those treated with other GEA modalities or hysterectomy over all time frames under commercial payer and Medicaid perspectives. By Year 3, cost savings versus other GEA were $930 (commercial) and $3,000 (Medicaid); cost savings versus hysterectomy were $6,500 (commercial) and $8,900 (Medicaid). Coinciding with a 43%-71% reduction in need for re-ablation, there were 69%-88% fewer intervention/reintervention complications for NovaSure-treated patients versus other GEA modalities, and 82%-91% fewer versus hysterectomy. Furthermore, NovaSure-treated patients had fewer days of work absence and short-term disability. Cost-effectiveness metrics showed NovaSure treatment as economically dominant over other GEA modalities in all circumstances. With few exceptions, similar results were shown for NovaSure treatment versus hysterectomy.

CONCLUSION

Model results demonstrate strong financial favorability for NovaSure ablation versus other GEA modalities and hysterectomy from commercial and Medicaid payer perspectives. Results will interest clinicians, health care payers, and self-insured employers striving for cost-effective AUB treatments.