Levonorgestrel-releasing intrauterine system

The LNG-IUS should always be considered after failure of other medical treatments and prior to any surgical procedure, as it can be inserted easily as an outpatient and does not have the operative risks associated with endometrial ablation or hysterectomy.

Endometrial ablation techniques

Various techniques are effective at treating menorrhagia by destroying the endometrium down to the basal layer, with the aim of preventing endometrial regeneration. The advantages over hysterectomy are shorter operating time, return home on the same day, shorter time off work and lower morbidity. However, endometrial ablation techniques have a lower cure rate and some women require a repeat ablation procedure or hysterectomy at a later stage.

Endometrial ablation is not suitable for women who may wish to become pregnant, and all women should be advised to continue to use contraception after the procedure.

Hysteroscopic endometrial ablation techniques

Complications of transcervical resection of the endometrium

Late complications

Pregnancies can occur after ablation techniques due to regrowth of endometrial tissue, so effective contraception should be used. Haematometra, from cervical fibrosis, is rare and should be drained. Endometrial cancer may occur in islands of residual endometrium, with the risk of delayed diagnosis if the malignant area is ‘walled off’ by fibrotic tissue.

Outcome of transcervical resection of the endometrium

At 1 year up to 66–87% of women are satisfied with TCRE, with 42% reporting amenorrhoea, 33% light periods and 16% no improvement. However, 10–38% have repeat surgery within 5 years and some eventually go on to have a hysterectomy. Endometrial ablation is more effective in older women. It may help with associated dysmenorrhoea and premenstrual symptoms, but is less likely to help if there is premenstrual pain. Success and complication rates both relate to the operator’s experience.

Non-hysteroscopic endometrial ablation techniques

Non-hysteroscopic endometrial ablation procedures, as described below, are known as the ‘second-generation’ ablation techniques and are performed ‘blind’. As such, endometrial polyps and small fibroids may be missed at the time of the procedure. However, the advantages of second-generation techniques are that they are generally simpler and quicker to perform, require less operator training and can often be carried out under local anaesthetic in the outpatient or day-surgery setting. Fluid overload does not occur and complications such as uterine perforation are very rare.

There is no significant difference in efficacy between the hysteroscopic and non-hysteroscopic techniques for patient satisfaction and reduction in heavy bleeding. Thirty to 60% of women become amenorrhoeic after the procedure.

Long-term safety and efficacy evidence is still awaited for these procedures.

Aetiology

The two commonest causes of primary amenorrhoea are Turner’s syndrome and constitutional delay (Fig. 5.2). Other causes include pregnancy, hypothalamic causes (stress, excessive exercise, anorexia), androgen insensitivity syndrome, hypothyroidism, primary ovarian failure and anatomical causes (uterine malformation, imperforate hymen and vaginal septum). Drugs that cause amenorrhoea are chemotherapeutic agents (damage to ovaries) or others such as phenothiazines, which are dopamine antagonists.

Figure 5.2 Causes of amenorrhoea in relation to the hypothalamopituitary–ovarian–endometrial axis. GnRH, gonadotrophin-releasing hormone; LH, luteinizing hormone; FSH, follicle-stimulating hormone; LNG-IUS, levonorgestrel-releasing intrauterine system.

Clinical features

A family history of female relatives with late onset of periods is suggestive of constitutional delay. Autoimmune disease or androgen insensitivity syndrome may also be suggested in the family history. Excessive exercise and any change in weight should be elicited. Chronic illnesses or medications should be asked about. An imperforate hymen or vaginal septum may present with a history of amenorrhoea and cyclical abdominal pain.

Examination

The important examination feature is the presence or absence of secondary sex characteristics such as breast development, pubic and axillary hair. Absence of such features by 14 years suggests ovarian dysgenesis (e.g. Turner’s), a hypothalamic cause or hypothyroidism.

The weight and height should be checked for calculation of body mass index.

Other features to note are signs of Turner’s syndrome (such as webbed neck and short stature), hypothyroidism or abnormal visual fields from a possible prolactinoma. Acne or hirsutism suggests androgen excess and clitoromegaly may suggest virilization or may represent ambiguous genitalia of congenital adrenal hyperplasia or an androgen-secreting tumour.

Investigations

Investigations should be initiated in a girl who has no periods by the age of 16 years if secondary sexual characteristics are present and at 14 if there is no secondary sex development.

A pregnancy test should be performed if there is a possibility of pregnancy. Thyroid function and prolactin levels should be checked. Serum gonadotrophin levels are high with low oestrogen in ovarian causes, such as Turner’s syndrome, previous chemotherapy or premature ovarian failure. Low gonadotrophins are found in hypothalamic causes such as weight-related and exercise-induced amenorrhoea. In PCOS, the testosterone and LH levels are high, with normal FSH.

Karyotype confirms the presence of Turner’s syndrome or other rare abnormalities, such as fragile X syndrome, and aids the diagnosis of androgen insensitivity.

Ultrasound scan should be arranged to confirm the presence of a uterus and exclude haematometra or haematocolpos.

In constitutional delay, the commonest cause of primary amenorrhoea, the examination and gonadotrophin results are normal.

Management

Girls with constitutional delay will menstruate spontaneously and reassurance should be given.

Other causes of primary amenorrhoea should be treated where possible; for example, thyroxine for hypothyroidism, bromocriptine or surgery for prolactinoma, hymenal division for haematocolpos. Exercise should be limited in those with exercise-induced amenorrhoea and weight gain encouraged if the body mass index is less than 19.

In causes such as Turner’s syndrome, androgen insensitivity and premature ovarian failure, extensive counselling is required for both the girl and her parents. Support groups exist for all these disorders and cover issues of self-image, sexuality and fertility. Osteoporosis should be prevented by long-term hormone replacement, usually in the form of the COCP.

History

The questions to ask include:

Examination

Examination should be directed by the history, looking for signs of PCOS (obesity, hirsutism and acne) or endocrine disease such as hypothyroidism. If a prolactinoma is suspected then the visual fields should be checked.

All women should have body mass index calculated. A bimanual examination may be indicated, for example to check for uterine size in suspected haematometra.

Investigations

A pregnancy test is usually indicated in secondary amenorrhoea. A hormone profile should then generally indicate the diagnosis.

In PCOS, a raised LH and moderately high testosterone are found in the majority of women. A very high testosterone level indicates further investigation for a possible androgen-secreting tumour, for example from the ovary or adrenal gland.

Premature ovarian failure is associated with raised FSH (>10 IU/l) and LH and with low oestradiol.

Hypothyroidism is associated with low thyroxine and raised thyroid-stimulating hormone.

Serum prolactin should always be checked, but caution is needed in interpreting the result as a prolactin level up to 1000 mU/ml may be due to stress, breast examination, PCOS or the venepuncture itself. True hyperprolactinaemia is usually caused by a microprolactinoma or occasionally a macroadenoma. Computed tomography or magnetic resonance imaging of the pituitary fossa and formal visual field testing should be arranged in cases of suspected prolactinoma.

Pelvic ultrasound is helpful where haematometra is suspected.

If premature ovarian failure is confirmed by gonadotrophin levels, then karyotype and autoimmune tests should be arranged for genetic causes and associated autoimmune disease, respectively.

If Asherman’s syndrome is suspected from previous uterine evacuation, then a hysteroscopy is indicated.