Presentations from the 34th Clinical Meeting of the AAGL Advancing Minimally Invasive Gynecology Worldwide held November 2005 in Chicago, IL, USA
Treatment Pathway Considerations for AUB
Thomas F. Purdon, MD FACOG
Clinical Professor of Ob-Gyn Arizona Health Sciences Center
Tucson, AZ
I have been working in this area for a long time but the longer I work in it, and the more I see the technology evolve, particularly the technology of endometrial ablation, the more I realize that there is a lot that is going on in this that involves patients ' choices and patients' options. You would have had to have been asleep today to not realize that there are all kinds of scientific gadgetry out there and lots of procedures that one could do. We had that wonderful pro and con debate this afternoon, that sort of thing. All of it is exciting and fun to participate in, but it is also important to realize, and try to take a look at what the evidence does support. Are we really offering the right options to our patients? And finally, what our patients are saying about what we are doing.
I do not really have to belabor this slide and tell the group just how important this whole subject is tonight. In fact, today, with several presenters you have seen similar data. I think we all quote a lot of this data. But it is true that over 20% of office visits in the United States for Gyns are for who are having abnormal uterine bleeding problems. It is a huge, huge, quality of life problem for our patients.
This is a cartoon characterization to just show you that in the age group of 35 to 55 there are some seven million women at any one time in the United States who are having serious abnormal uterine bleeding problems.
Of that group approximately 1.8 million are women who need to choose something that is temporary. Obviously the only thing that we have for them is some type of hormonal manipulation, or some type of antifibrinolytic medication, which I am going to talk about in a moment. But we also recognize that maybe now that is a group of women that, if we can get them over the hump, and they can have their children and use that uterus, if they have trouble again, they will have another option. Certainly there are some negatives as far as hormone therapy; it is certain to continue on it for a long time does not work for every woman. We know that.
Then of course there is a group of women that have surgical intervention. We know of course what that is; we have been talking about that all day long.
This is an interesting slide of rates in the United States, although the data is really unfortunately still slow in coming in. It does not show a very large change, if you will, of the often-quoted figure of some 650,000 hysterectomies. So far we have not seen that go down much. My prediction is though that with the way endometrial ablation has exploded, that we are going to see that change very, very soon.
It is changing in the UK. There may be some people in the audience who recognize this. It is right out of an article from the British Medical Journal showing, finally, a little drop in their data as you can see here starting at about 1999, and on. They ascribe this to two things: they ascribe it to endometrial ablation and, they ascribe it to an intrauterine system with a hormone active product.
What about the causes of the abnormal bleeding? There is an interesting thing that I have been paying a lot of attention to lately. I will bet you there are people in the audience, particularly if you are from the UK or Australia, who have done the same thing. This is just a very brief slide out of Mishell's textbook, and you will notice down at the bottom, under the dysfunctional uterine bleeding, we have assumed in the United States, and I think I submit to you, erroneously, that 90+% of so-called DUB is related to anovulation. And maybe only 10% at most, is related to ovulatory cycles.
What about the anovulatory cycles? Well, again, I do not have to explain to this group that it is non-cyclic, it is hormone deficits, it is estrogen ups and downs and withdraws, it is lack of progesterone to cement the stroma and take care of the uterus and so on, or the endometrium. But it is certainly that type of bleeding that is usually erratic both in timing and in volume.
However, the ovulatory abnormal bleeding usually is regular and cyclic. As a matter of fact, in the UK in particular, but also in Australia, New Zealand and Canada, our colleagues there ascribe a much higher percentage of abnormal bleeding, they call it generally DUB, to ovulatory cycles. I think we are going to see something about this in publication very soon in the United States. Several of us who participated in a study think that maybe that data will show that there is more ovulatory dysfunctional bleeding in the United States than we have paid attention to.
And of course, if that is so, why would we, in that group of patients, want to continue to persist with hormonal therapy? It is probably not going to work. Maybe we should try antifibrinolytics, etc. But certainly to persist with hormone therapy does not make a lot of sense on an evidence-based approach.
Some recent surveys have been showing us that women have some ideas and perceptions too. This happens to be some data from Women's Health Resource Center group, and of patients who had been treated for abnormal uterine bleeding in the last five years. So it does go back really before the big explosion of course of Global Endometrial Ablation.
Interestingly 79% desired reduction in bleeding, and only 18% really thought they wanted absolutely amenorrhea. I will not read all of the statistics for you as you can see for yourself. But in my part of the country, with a very high Hispanic population, I can tell you that a high percentage of my patients are not so keen on having total amenorrhea. In fact, they worry that there is something really wrong with them if they are not having some kind of a menstrual period. Perceptions are very important.
In a group from that same study they had women who had not received treatment but they were given an instruction as part of the survey technique about various options for them. This is what that shows. Sixty-two percent would choose hormone therapy. Fifty-two percent would choose endometrial ablation, which is really an interesting and high percentage, I think. Thirty-six percent would like something that would reduce the bleeding. But only 30% preferred to have it eliminated completely. I like the last one. Fifty-five percent said that they would go get another opinion if their Ob-Gyn would not help them. I guess I am very much in favor of that too, as a matter of fact.
In all of the women's perceptions taken together, 97% agreed that a woman should be given a choice on how to treat heavy bleeding. Twenty-two percent said that the Ob-Gyn should really try to help that woman and convince her to take a type of treatment that would be best directed to her. And patients do say they want better explanations. The bottom line on this survey is that women want more choices, and they want options. And for many of those women, endometrial ablation is clearly an answer for them.
Our next speaker probably needs no introduction for this group but I am going to do it anyway, because that is what I am supposed to do tonight. And that is Dr. Ted Anderson. Ted is an Associate Professor in the Department of OBGYN, at Vanderbilt University Medical Center in Nashville. He is an arduous, arduous worker in this subject, along with other subjects regarding the technology of medicine. Dr. Anderson.