may 2012 judith ten hof n.
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May 2012 Judith ten Hof. Bleeding problems. Bleeding problems. Abnormal/dysfunctional Bleeding Regular monthly and heavy Regular monthly with intermenstrual bleeding Irregular periods Irregular bleeding Post coital bleeding Post menopausal bleeding

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bleeding problems
Bleeding problems
  • Abnormal/dysfunctional Bleeding
    • Regular monthly and heavy
    • Regular monthly with intermenstrual bleeding
    • Irregular periods
    • Irregular bleeding
    • Post coital bleeding
    • Post menopausal bleeding
    • Unscheduled bleeding on contraceptives
heavy menstrual bleeding
Heavy menstrual bleeding
  • 1/20 women consult GP every year
  • 1990’s at least 60% hysterectomy
  • NICE clinical guideline 44
what s new
What’s ‘new’
  • Terminology
  • Pharmaceutical treatments
  • Endometrial ablation procedures
  • Uterine artery embolisation
  • Increase minimal access procedures
  • National Heavy Menstrual Bleeding Audit
heavy menstrual bleeding in primary care
Heavy Menstrual Bleedingin primary care
  • 50% patients received some treatment in primary care (reported 83% of hospitals)
  • No pts received treatment in primary care (37% of hospitals)
  • ‘Guidelines should be in place for direct referral to imaging services from primary care’ (RCOG standards).
  • GPs could refer directly to imaging services (99.1% of hospitals).
  • It was less common for GPs to be able to refer directly to pathology (42.7%) and other diagnostic procedures (21.8%).
  • Only one hospital said that GPs could not refer directly to any services.
  • (First annual report of the National Heavy Menstrual Bleeding Audit 2011)
heavy menstrual bleeding in secondary care
Heavy Menstrual Bleedingin secondary care
  • Additional investigations:
    • TV USS
    • Pipelle biopsy
  • Options:
    • Medication non hormonal
    • Hormonal
    • IUS
    • Endometrial ablation
    • Hysterectomy
    • Larger fibroids:
      • Embolisation
      • Hysteroscopic resection
      • Myomectomy
      • Hysterectomy
patterns of surgical treatment over time
Patterns of surgical treatment over time

Figure 3.1 Number of surgical operations for women with HMB in English NHS

trusts between 1 April 1997 and 31 December 2009

irregular bleeding
Irregular bleeding
  • No guidance
  • History:
    • Irregular periods
      • likely hormonal problem: PCOS, anovulatory cycles
    • Regular periods with IMB:
      • IU abnormality/infection
    • Irregular constant bleeding :
      • Hormonal, abnormality/infection
    • Post coital bleeding
    • Post menopausal bleeding
    • Unscheduled bleeding on contraceptives
irregular bleeding in primary care
Irregular bleeding in primary care
  • Bleeding calendar might be helpful
  • Pt age
  • Other symptoms
    • eg pelvic pain
    • Hormonal dysfunction hirsutism, galactorrhoea
    • Ovulation pain
  • Family history
irregular bleeding in primary care1
Irregular bleeding in primary care
  • BMI
  • Abdominal examination
  • Speculum and bimanual
  • Triple swabs
  • Pipelle (>40-45yrs)
  • USS
irregular bleeding in primary care2
Irregular bleeding in primary care
  • Depending on clinical suspicion of IU abnormality
    • Refer
      • Heavy and irregular bleeding perimenopausal consider hysteroscopy, EB +/- Mirena
    • Trial to regulate cycle with COCP/ cyclical progesterone
post coital bleeding
Post-coital bleeding
  • Bleeding during or after sexual intercourse
  • More likely from vagina or cervix than endometrium
    • vaginal:
      • vaginitis
      • carcinoma - very rare
    • cervix:
      • ectropion
      • cervicitis
      • polyps
      • carcinoma - the most likely malignant cause of PCB
      • trauma
  • Can be a sign of serious underlying pathology and is the classical symptom of cervical carcinoma
  • Prevalence in large community surveys :0.7-9 percent
  • Can be referred urgently
post coital bleeding1
Post-coital bleeding

Shapley, Br J Gen Pract. 2006 June 1; 56(527): 453–460.

post coital bleeding in primary care
Post-coital bleeding in primary care
  • History
    • duration & frequency of symptoms
    • Smear history
    • Sexual
    • Use of contraceptives
  • Examination:
    • Speculum and pelvis
    • Triple swabs
  • Findings:
    • Atrophic vaginitis treat
    • Cervical polyp  avulse & histology
    • Swabs pos  treat & review after 6-8 wks
  • No suspicion cancer:
    • <25 refer gynae clinic
    • >25 refer colposcopy
    • With intermenstrual bleeding refer gynae clinic
  • Suspicious cervical cancer: urgent 2WW referral
post menopausal bleeding
Post-menopausal bleeding
  • SIGN guideline 61, 2002
  • Definition:
    • Vaginal bleeding > 12 months after LMP
    • Unscheduled/abnormal bleeding on HRT
      • On continuous combined/Tibolone:
        • >6mths of treatment
        • After amenorrhoea
      • On sequential regimens:
        • Heavy/prolonged after progestogen phase
        • Bleeding at any other time
post menopausal bleeding1
Post-menopausal bleeding
  • 5% of referrals to gynaecology
  • Can be symptom of abnormality:
    • Endometrial cancer present in 10%
    • Endometrialhyperplasia
    • Intra-uterine abnormality
    • Vaginal/Cervical problem egvaginitis, cervical polyp
post menopausal bleeding2
Post-menopausal bleeding
  • Riskfactors:
    • Age
    • HRT
    • Tamoxifen
    • Other:
      • hereditary cancer syndromes
      • obesity, BM, hypertension, PCOS
      • (Unopposed oestrogen exposure)

Incidence of vaginal bleeding (per 1000) - - - - - -

% endometrium carcinoma

Age(yrs)

tv ultrasound
TV ultrasound
  • Endometrium is thin post-menopausal
  • Thickness can be measured by TV USS
  • Treshold thickness depends on sensitivity and specificity

Endometrial cancer

on Tamoxifen

transvaginal ultrasonographic tvus evaluation of women with post menopausal bleeding
Transvaginalultrasonographic (TVUS) evaluation of women with post-menopausal bleeding

SIGN guideline 61, 2002

post menopausal bleeding3
Post-menopausal bleeding
  • Where indicated and patients on Tamoxifen:
    • Hysterospcopy + endometrial biopsy
    • Biopsy alone
  • Recurrent bleeding needs further investigation
post menopausal bleeding in primary care
Post-menopausal bleeding in primary care
  • History:
    • duration & frequency of symptoms
    • Smear history
    • Use of HRT/ contraceptives
  • Examination:
    • Speculum and pelvis
    • ?pipelle
    • Triple swabs
  • Findings:
    • Atrophic vaginitis treat
    • Cervical polyp  avulse & histology
    • Swabs pos  treat & review after 6-8 wks
  • ?Access to ultrasound
  • Refer if symptoms not resolved
  • Suspicious/confirmed endometrial cancer: urgent 2WW referral
unscheduled bleeding on hormonal contraception
Unscheduled bleeding on hormonal contraception
  • FSRH guidance May 2009
  • Often due to contraceptive:
    • superficial bloodvessel fragility in endometrium
    • change in endometrial steroid response
    • angiogenic factors
  • Cancer rare
unscheduled bleeding on hormonal contraception1
Unscheduled bleeding on hormonal contraception
  • History:
    • Contraception method, duration and use
    • Other medication
    • Smear history
    • Risk STD
    • Bleeding pattern prior to contraception
    • Other symptoms: pain, dyspareunia, PCB
    • pregnancy
unscheduled bleeding on hormonal contraception2
Unscheduled bleeding on hormonal contraception
  • Examination if:
    • Persistent > first 3-6mths/ change in bleeding pattern)
    • Not in cervical screening
    • Failed medical treatment
    • Pt request
    • Speculum+ bimanual +/- pipelle
    • USS
    • Hysteroscopy + EB
unscheduled bleeding on hormonal contraception therapy
Unscheduled bleeding on hormonal contraception. Therapy
  • COCP
    • change to EE 35mcg
    • try different pill
  • POP
    • try different (no evidence that changing progesterone improves bleeding/ desogestrel is better)
    • No evidence double dose
  • Implants/depoprover/implant
    • Add COCP 30/35mcEE+levonorgestrel/norethisterone
    • No evidence reducing injection interval
    • Mefenamic acid for 5 days
case1 pd 26yrs
Case1: PD 26yrs
  • Reg heavy periods
  • Po, Female partner
  • Tired otherwise well
  • O/E inclgynae
    • Normal findings
case 2 jc 79 yrs
Case 2: JC 79 yrs
  • 1 episode red bloodloss on wiping
    • Menopause age 52. No discharge
    • Not sexually active
    • H/O Breast cancer
    • Examination by GP:
      • Speculum difficult vaginal atrophy
      • No abdo masses, cervix palpates normal
    • Single episode
    • H/O haemorrhoids
    • TV-USS: ET 3mm, small fibroid 16mm, nl ovaries
case 3 aa 50yrs
Case 3 AA 50yrs
  • Ref:
    • Irregular menstrual cycle, heavy bleeding
    • USS: bulky ut, 23mm fibroid, ET 13mm, nlov
  • Cycle: 1x/2-3 mths, more heavy
  • IMB and spotting
  • No climacteric symptoms
  • Married sexually active, no pain
  • Smears up to date
case 4 cs 23 yrs
Case 4 CS, 23 yrs
  • Bleeding after sex
    • Implant in situ 2 yrs
    • Irreg small bleeds
    • Same partner 8mths
  • O/E
    • Cervix red and bleeds easily