Dr Kristina Naidoo Consultant Gynaecologist

Menstrual Disorders

 Defining normality  Defining problem  Investigations  Treatment

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.

Menarche/Menopause

 Menarche average age 12.9

 Anovulatory cycles 80% in first year, 10% in 6 th year  Menopause 42-58 (average 51)  Postmenopausal bleeding > 1 year after the last menses

Symptoms of AUB

 Heavy menstrual bleeding  Intermenstrual bleeding (IMB)  Postcoital bleeding (PCB)  Irregular menstrual cycle  Postmenopausal bleeding  +/-pain

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

When to refer Suspected 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

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

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

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)

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.

Submucous fibroid and Mirena IUS

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.

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.

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.

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.

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.

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

‘One stop’ Menstrual Dysfunction Clinic

Conventional pathway ‘One stop’ pathway

‘One stop’ menstrual dysfunction clinic General Gynaecology Clinic ?biopsy

Pelvic scan Review, list for Day Case Hysteroscopy Pre-operative assessment clinic Hysteroscopy under GA Follow-up to plan management

Outpatient Hysteroscopy

 RCOG recommendation  2012 favourable tariff  Diagnosis of benign intrauterine pathology  Treatment  Resection polyps, small fibroids, RPOCs  IUD retrieval

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