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How to manage menstrual disorders in general practice and when to refer to secondary care

How to manage menstrual disorders in general practice and when to refer to secondary care. Dr Kristina Naidoo Consultant Gynaecologist. Menstrual Disorders. Defining normality Defining problem Investigations Treatment. Normal menstruation. Most menstrual cycles 22 to 35 days

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How to manage menstrual disorders in general practice and when to refer to secondary care

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  1. How to manage menstrual disorders in general practice and when to refer to secondary care Dr Kristina Naidoo Consultant Gynaecologist

  2. Menstrual Disorders • Defining normality • Defining problem • Investigations • Treatment

  3. Normal menstruation • Most menstrual cycles 22 to 35 days • Normal menstrual flow 3 to 7 days • Most blood loss occurs within first 3 days • Menstrual flow amounts to 35ml* • In general, most normal menstruating women use five or six pads or tampons per day.

  4. Menarche/Menopause • Menarche average age 12.9 • Anovulatory cycles 80% in first year, 10% in 6th year • Menopause 42-58 (average 51) • Postmenopausal bleeding > 1 year after the last menses

  5. Symptoms of AUB • Heavy menstrual bleeding • Intermenstrual bleeding (IMB) • Postcoital bleeding (PCB) • Irregular menstrual cycle • Postmenopausal bleeding • +/-pain

  6. FIGO classification of Causes of AUB (non-pregnancy)PALM-COEIN • P polyps • A adenomyosis • L leiomyoma • M malignancy & hyperplasia • C coagulopathy • O ovulatory disorders • E endometrial causes • I iatrogenic • N not classified

  7. When to referSuspected cancer- symptoms • PCB lasting more than 4 weeks over 35 years • IMB persistent and unexplained • 1 or more episodes of PMB and NOT on HRT • Persistent or unexplained PMB 6/52 after cessation of HRT • Any unscheduled bleeding on Tamoxifen • NOT Repeated, unexplained PCB

  8. When to refer Suspected cancer- signs • Palpable abdominal/pelvic mass not obviously fibroids/urinary or GI • Lesion on cervix suspicious of cancer • Unexplained vulval lump • Vulval bleeding due to ulceration

  9. Heavy Menstrual Bleeding(HMB) • Excessive menstrual blood loss which interferes with a woman's physical, social, emotional and/or material quality of life • It can occur alone or in combination with other symptoms

  10. HMB • Blood loss is subjective • 30% women consider their bleeding to be excessive • Half of these have a normal blood loss (<80ml) • Women aged 30-49, 1:20 consults GP re HMB each year • HMB accounts for 12% of Gynae referrals • £7 million a year spent on prescriptions in primary care (2007)

  11. Mirena LNG-IUS • Provided long-term use (at least 12 months anticipated) • Prevents endometrial proliferation. • Contraceptive. • Doesn't impact future fertility. • Unwanted outcomes: irregular bleeding that can last for six months; amenorrhoea; progestogen-related problems such as breast tenderness, acne and headaches; uterine perforation at insertion (1 in 100,000 chance). • As equally effective in improving quality of life and psychological well-being as hysterectomy.

  12. Submucous fibroid and Mirena IUS

  13. Tranexamic acid • Oral antifibrinolytic . • If no improvement, stop after three cycles. • Unwanted outcomes: indigestion; diarrhoea; headache. • No increased risk of thrombosis. Cochrane review. • Dose: 500 mg tablets. 2 to 3 tablets (1-1.5g three to four times daily for three to four days. From onset of heavy bleeding.

  14. NSAIDs • Commonly used: mefenamic acid • Reduce production of prostaglandin. • If no improvement, stop after three cycles. • Preferred over tranexamic acid in dysmenorrhoea. • Unwanted outcomes: indigestion; diarrhoea; worsening of asthma • Dose: mefenamic acid 500 mg tablets. 1 tablet three times daily during heavy bleeding.

  15. COCPs • Prevent proliferation of the endometrium. • Also act as a contraceptive. • Do not impact future fertility. • Unwanted outcomes: mood change; headache; nausea; fluid retention; breast tenderness; DVT; MI; CVA.

  16. Oral progestogen • Commonly used: Norethisterone • Prevents proliferation of the endometrium. • Does not impact future fertility. • Dose: 15 mg daily on days 5-26 of the cycle. • Unwanted outcomes: weight gain; bloating; breast tenderness; headaches; acne; depression. • A recent Cochrane Review showed that this regime of progestogen results in a significant reduction in menstrual blood loss but that women find the treatment less acceptable than intrauterine levonorgestrel.

  17. Injected progestogen • Depot-medroxyprogesterone acetate • Prevents proliferation of the endometrium. • Contraceptive. • Does not impact on future fertility. • Unwanted outcomes: as for oral progs; weight gain; irregular bleeding; amenorrhoea; bone density loss. • Current guidance: • Use in adolescents as last resort. • Other women re-evaluate after 2 years, if significant risk factors for osteoporosis consider alternative.

  18. When to refer • Suspicion from history of increased risk of pathology: • E.g. family history of endometrial or colonic cancer • Infertility/nulliparity • Obesity/diabetes • Unopposed oestrogen therapy • PCOS

  19. ‘One stop’ Menstrual Dysfunction Clinic

  20. Outpatient Hysteroscopy • RCOG recommendation • 2012 favourable tariff • Diagnosis of benign intrauterine pathology • Treatment • Resection polyps, small fibroids, RPOCs • IUD retrieval

  21. Conclusions • Reassurance re normal patterns of bleeding • Full blood count -first line investigation • Low threshold for pelvic scanning (TVS) • Hormonal contraception for HMB • Red flag symptoms-> HSC205 pathway • Risk factors for endometrial pathology-> refer early • ‘One stop’ clinics advantageous

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