max brinsmead phd franzcog july 2011 n.
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Max Brinsmead PhD FRANZCOG July 2011. IRREGULAR VAGINAL BLEEDING in a WOMAN BEFORE MENOPAUSE . The common causes are…. Pregnancy-related Miscarriage – threatened, inevitable or incomplete Ectopic Cervical Bleeding Benign Ectropion, Cervicitis or Polyp Cancer of the cervix

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the common causes are
The common causes are…
  • Pregnancy-related
      • Miscarriage – threatened, inevitable or incomplete
      • Ectopic
  • Cervical Bleeding
    • Benign
        • Ectropion, Cervicitis or Polyp
    • Cancer of the cervix
        • Rare in patients who have regular Pap smears)
  • Bleeding from the uterine cavity
    • Benign
        • Fibroids and Polyps
        • Cancer
    • Dysfunctional uterine bleeding
        • A diagnosis made after excluding other causes
but also keep in mind
But also keep in mind…
  • Hormones that have been given
      • Depoprovera (or DMP or DMPA)
      • Oral contraceptives (COC)
      • Other (some OTC drugs affect cycles)
  • Bleeding disorders
      • Rare
      • Usually associated with other bleeding or bruising
when a patient complains about abnormal vaginal bleeding
When a patient complains about abnormal vaginal bleeding...
  • First determine if she has:
      • Regular but heavy or prolonged periods
        • This is called menorrhagia
        • It is a common manifestation of fibroids
        • Rarely due to a bleeding disorder
      • Regular periods with bleeding at other times
        • If the bleeding is postcoital it should be regarded as cancer of the cervix until proven otherwise
      • Irregular bleeding
        • This may be dysfunctional uterine bleeding but this diagnosis is can only made when other causes are excluded
  • And always exclude pregnancy
        • Best done by pregnancy test
consider your patient s age
Consider your patient’s age…
  • If the patient is young (<40 years)
      • Endometrial cancer is uncommon
      • But Ca cervix always needs to be ruled out
  • If the patient is very young & never sexually active
      • Pregnancy, STD and Ca cervix never occurs
      • But dysfunctional uterine bleeding is not uncommon
  • If the patient is >45 years
      • Cancer from within the uterine cavity can only be excluded by endometrial biopsy or curette
      • Check also for Ca cervix
      • But dysfunctional bleeding is not uncommon
you must always examine
You must always examine…
  • Look for signs of anaemia
  • Examine the abdomen to see if there is a uterus or other mass arising out of the pelvis
  • Pass a speculum and decide if the bleeding is coming from or through the cervix
  • Look carefully at the cervix
  • Examine the pelvis bimanually to see if the uterus is enlarged
      • (And if the cervix feels normal even if it looked abnormal)
tests you should perform
Tests you should perform
  • FBC to check HB & platelet count
  • Pap smear if not recently performed
    • But this is not a test for cervical cancer!
  • Cervical or 1st voided urine for Chlamydia if the patient is at risk of STD
  • Ultrasound of the uterus has a limited role
    • But should be performed if the uterus is enlarged
    • It is NOT a substitute for clinical examination
dysfunctional uterine bleeding dub
Dysfunctional Uterine Bleeding (DUB)
  • There is often a history of missed periods or irregular cycles
  • May be associated with obesity and hirsutism (PCO Disorder)
  • Bleeding is usually painless
    • Unless there is clot colic
  • Bleeding can be very heavy or quite prolonged
  • There is a normal cervix and the uterus is not enlarged
management of abnormal vaginal bleeding
Management of Abnormal Vaginal Bleeding
  • Antibiotics are indicated only for proven STI
  • Bleeding from an abnormal cervix is rarely a life-threatening emergency
    • But it generally requires referral for further testing and treatment
  • Transfusion should be reserved for those with severe anaemia and in whom you cannot immediately control the bleeding
  • Uterine bleeding after the age of 45 requires referral for D&C or biopsy
  • Dysfunctional uterine bleeding can be treated with oral hormone therapy (Progestin or COC)
management of dysfunctional uterine bleeding
Management of Dysfunctional Uterine Bleeding
  • Bleeding can be controlled with Norethisterone
  • Give 2x 5m tablets every 2 – 3 hours until the bleeding slows or stops
  • Then 5 mg BD for 10 – 14 days
  • The patient can then expect a “normal period” a few days after stopping the pills
  • Give COC in the next cycle
  • or Norethisterone 5 mg BD from day 10 – 25 of each cycle for 4 – 6 months
  • Give oral iron ± folate to treat anaemia
emergency treatment of any endometrial bleeding
Emergency treatment of any Endometrial Bleeding
  • When the blood is coming through the cervix
  • Even if the patient is >45 years
  • Or if the uterus is enlarged by adenomyosis or fibroids
  • Or the patient has a bleeding disorder
  • You can try Norethisterone 10 mg every 2 – 3 hours
  • But refer also for further Ix and Rx
management of hormone related pv bleeding
Management of Hormone-related PV bleeding
  • Irregular PV bleeding with Depoprovera or COC is secondary to their effect on the endometrium
  • But make sure that the cervix is normal
  • Then try Norethisterone as per DUB regimen
    • Or give Premarin 1.25 mg 8 hourly
    • Or any COC one tablet 6 hourly
    • Or just give another injection of Depot Provera
    • An episode of bleeding can be shortened with Mefanamic acid 500 mg BD for 5 days