Modern approaches to the treatment of abnormal uterine bleeding in women with the metabolic syndrome and genital prolapse

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Kharkiv National Medical University

Modern approaches to the treatment of abnormal uterine bleeding in women with the metabolic syndrome and genital prolapse

Harkavenko K.V.,

Safonov R.A.,

Lazurenko V.V.

Kharkiv, Ukraine

Annotation

Abnormal uterine bleeding (AUB) is an urgent problem of modern gynaecology. Deficiency of sex hormones in peri- and postmenopause is a triggering factor for the development of dyslipidemia, endothelial dysfunction, abdominal obesity, insulin resistance, arterial hypertension, the formation of the so-called metabolic syndrome (MS), the prevalence of which reaches 25-35%, and at the age of over 60 - 40-45%. Genital prolapse (GP), especially in the postmenopausal period, is often detected during the examination of women with AUB against the background of metabolic syndrome, which also requires timely diagnosis and, if necessary, surgical treatment.

The work aimed to improve the treatment of AUB in women of peri- and postmenopausal age with metabolic syndrome and genital prolapse. Twenty-three women with AUB and MS and GP (main group) and 25 women with AUB and MS (comparison group) were examined to achieve the goal. The control group consisted of 15 women who did not have gynaecological and somatic pathology. In the main group of perimenopausal women, operative treatment was performed in the form of hysteroresectoscopy in combination with colporrhaphy and colpoperineorrhaphy and/or sacrospinal fixation of the vaginal dome with mesh prostheses. Transvaginal extirpation was conducted in the postmenopausal period. Hysteroresectoscopy was performed in women of the comparison group. Rational treatment of patients with AUB and comorbid pathology (MS, GP) depends on the patient's age and the degree of GP: in the perimenopausal age - hysteroresectoscopy with colpoperineorrhaphy; in postmenopause - transvaginal extirpation with sacrospinal fixation vaginal dome with mesh prostheses.

Key words: abnormal uterine bleeding, metabolic syndrome, genital prolapse.

Introduction

Abnormal uterine bleeding (AUB) is an urgent problem of modern gynaecology. For example, 1.4 million women in the USA seek help for this pathology every year [1]. AUB occurs in almost 70% of patients during the perimenopausal period and in postmenopause due to significant changes in hormonal homeostasis, particularly sex hormones [2]. Deficiency of sex hormones in peri- and postmenopause is a trigger for the development of dyslipidemia, endothelial dysfunction, abdominal obesity, insulin resistance, arterial hypertension, and the formation of the so-called metabolic syndrome (MS), the prevalence of which reaches 25-35%, and at the age of over 60 - 40-45% [3]. Women with AUB, especially with obesity or other signs of MS, in the peri- and postmenopausal period need to be evaluated for precancerous lesions, such as endometrial hyperplasia and endometrial polyps [4]. Also, the frequency of AUB complications increased, particularly anaemia, hypovolemia, and potential hemodynamic instability [5]. After determining the etiological causes according to the PALM-COEIN classification, medical management of AUB is aimed at pathogenetic treatment and elimination of complications using intravenous conjugated estrogen, multidose COCs or oral progestins and tranexamic acid [1]. The decision on operative treatment is based on the medical history, comorbid diseases and contraindications to drug therapy. An acute AUB episode should be controlled with further long-term observation and treatment [5].

Genital prolapse (GP), especially in the postmenopausal period, is often detected during the examination of women with AUB against the background of metabolic syndrome, which also requires timely diagnosis and, if necessary, surgical treatment [6]. Pelvic floor dysfunction occurs in more than 50% of older women and impairs their quality of life due to pelvic pain, GP, urinary and faecal incontinence. Age and female gender, in combination with obesity and connective tissue dysplasia, increase the risk of developing HP [7]. At the same time, some patients with AUB and GP refuse to take hormone therapy due to fear of obesity and repeated AUB. In such cases, it is necessary to offer diagnostic and therapeutic approaches that would be highly effective in treating comorbid pathology, an urgent task of modern gynaecology.

The aim of the study. To improve the treatment of AUB in women of peri- and postmenopausal age with metabolic syndrome and genital prolapse.

Object and research methods. To achieve the goal, 23 women with AUB and MS and GP (main group) and 25 women with AUB and MS (comparison group) who were treated in the gynaecological department of the Kharkiv Regional Perinatal Center of the Communal non-profit enterprise of the Kharkiv Regional Council "Regional Clinical Hospital" were examined. The control group consisted of 15 women who did not have gynaecological and somatic pathology. The study followed the principles of the Declaration of Helsinki of the World Medical Association, "Ethical Principles of Medical Research Involving Human Subjects" (amended in October 2013). Written informed consent was obtained from all women participating in the study.

The examination included a general clinical and laboratory examination of blood, urine and anthropometric measurements of height, weight, BMI, waist/hip ratio. Diagnosis of MS was carried out following the common position of the IDF, NHLBI, AHA, WHF, IAS, and IASO, according to which MS must meet 3 of 5 criteria [3]:

1. increased waist circumference - more than 80 cm in women of the European population;

2. triglyceride concentration greater than 1.7 mmol/l (150 mg/dL) or treatment of hyperglyceridaemia

3. HDL-C concentration less than 1.3 mmol/L (50 mg/dL) in women or treatment of lipid disorder

4. systolic blood pressure greater than 130 mm Hg or diastolic blood pressure greater than 85 mm Hg or hypertension treatment

5. fasting plasma glucose concentration greater than 5.6 mmol/l (100 mg/dL) or treatment for T2DM.

Transvaginal and transperineal ultrasound examinations were performed using the GE Voluson system and MRI. The quantitative evaluation of GP (POR-Q) (1996) was used to determine the degree of prolapse. In the main group of women of perimenopausal age, operative treatment was performed by hysteroresectoscopy on the Karl Storz (Germany) device combined with col- porrhaphy and colpoperineorrhaphy and/or sacrospinal fixation of the vaginal dome with mesh prostheses.

Transvaginal extirpation was performed in the postmenopausal period. Hysteroresectoscopy was performed in women of the comparison group. The choice of surgical tactics was based on the features of the pathology and the patient's consent to the scope of the surgical intervention.

The morphological and histological study of the material obtained during surgical treatment was carried out in the pathomorphology department of the Kharkiv Regional Clinical Hospital. Statistical processing of the obtained results was performed using the "Statistica 6" program.

pathological uterine bleeding metabolic genital prolapse

Research results and their discussion

The average age of the patients was 60.5±5.2 years. In the main group - 65.9±4.1 years; in the comparison group - 54.6±3.7 years; in the control group - 51.8±2.3 years. BMI was 29.8±2.1 kg/m² in the main group, 31.5±3.4 kg/m² in the comparison group, and 25.7±1.5 kg/m² in the control group. Ultrasound of the internal genital organs revealed endometrial hyperplasia in 73.9% of women in the main group and 56% in the comparison group. In other cases, endometrial polyps were detected. As a result, we obtained statistically significant data showing that patients with precancerous lesions had a higher body weight (BMI), especially postmenopause. It was noted that AUB in patients with increased weight or obesity in the postmenopausal period indicates a high risk of precancerous lesions, and this is very important for choosing further treatment tactics.

During the transperineal ultrasound, a levator defect was identified in 15 (65.2%) women in the main group. In almost half of them, the defect was bilateral, confirmed by visualization of the vaginal entrance and by measurement of the area of the vaginal opening, indicating a diagnosis of levator detachment [ 8]. The aetiology of GP includes overstretching or tearing of m. levator ani. The use of endovaginal ultrasonography allows for measuring the anterior-posterior (AP) diameter, the transverse size (left-right (LR) diameter) and the minimal levator hiatus area [9]. The AP/LR ratio corresponds to the shape of the pelvic floor muscles (oval or circular). Postmenopausal women had high AP/LR compared to controls and perimenopausal women, indicating that m. levator ani changes the genital opening to a more oval shape in postmenopausal women, and these changes are associated with increased symptoms of GP.

Histological examination of the obtained material in the main group revealed glandular-cystic, adenomatous polyps of the endometrium with foci of necrosis and dysplasia, glandular-polypous hyperplasia of the endometrium; in the comparison group - mainly glandular hyperplasia of the endometrium, fibrous polyps of the proliferative type.

When studying the relationship between the symptoms of GP and other factors, in particular the stage of prolapse on the one hand and the functional anatomy of the pelvic floor on the other hand, it was determined that among women with GP, there was none with a cesarean section (CS), which indicates the importance of underwent labour in further development of GP and which coincides with the data of Akervall S et al., who determined that GP occurs in women who had vaginal labour 13.2 times more often than those who underwent CS [10].

Pelvic floor dysfunction is often multicomponent, so insufficient diagnosis often leads to inadequate treatment. Dynamic MRI is a reliable tool and allows simultaneous visualization of all three floors of the pelvic floor and is therefore indispensable for an accurate preoperative assessment, especially in women with metabolic syndrome [7].

AUB is a frequent symptom in perimenopausal women, negatively affecting their quality of life and normal physiology. In the presence of structural pathology of the uterus, a hysterectomy relieves symptoms and improves the quality of life and sexual function [11]. At the same time, alternative hysterectomy methods, such as hysteroscopic polypectomies, myomectomies, endometrial resection or ablation, are considered minimally invasive techniques and can be used as alternative hysterectomy methods of treating AUB in benign conditions. It is also associated with high patient satisfaction, short recovery time, and improved quality of life [12, 13]. At the same time, hysteroscopic treatment does not exclude the risk of AUB recurrence or subsequent surgical intervention. Thus, taking into account the impact of various treatment methods on the quality of life, including sexual, during the perioperative examination, the decision to perform and identify care should be very appropriate and personalized for women with MS in the perimenopausal and postmenopausal period in the presence of AUB and GP [14, 15].

Conclusions

Rational treatment of patients with AUB and comorbid pathology (MS, GP) depends on the patient's age and the degree of GP: in the perimenopausal age - hysteroresectoscopy with colpoperineorrhaphy; in postmenopause - transvaginal extirpation with sacrospinal fixation of the vaginal dome with mesh prostheses.

Prospects for further research. In the future, it is planned to compare the results of using mesh endoprosthesis and allograft in women with AUB, MS and genital prolapse.

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