Transcript IMB & PCB in Women Presentation

Unscheduled bleeding in young
women
Dr Kathryn Hill
GPST2 in O+G
Aims
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To review the guidelines on the management of abnormal
vaginal bleeding in young women
To concentrate on the investigation/ management to be
carried out before referral to colposcopy clinic
Why is it important?
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1/600 women aged 20-24y reported PCB per year
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0.5-1% women aged 20-24y present with IMB/ year
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Estimated 7500 – 15000 women will present each year
DoH Clinical Practice Guidelines
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Women aged 20-24y
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Abnormal vaginal bleeding relatively common
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To prevent delay of referral to colposcopy in rare cases of
cancer
Management - PCB
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History
Speculum examination
If clinically suspicious 2ww
If local problem treat or refer
If normal for swabs
Refer if bleeding persists 6-8 weeks
Women over 35y PCB >4w refer colposcopy (Scottish
Guidelines)
Management - IMB
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History
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If suspected OCP problem – modify contraception
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If bleeding persists (6-8 weeks) – speculum
FSRH - management of unscheduled
bleeding on hormonal contraception
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Frequent / prolonged / irregular / spotting
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Many due to method of hormonal contraception
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Endometrial and cervical cancer rare
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Early vs late symptoms
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May not need examination
FSRH - management of unscheduled
bleeding on hormonal contraception
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COCP/ Patch/ Ring:
Upto 20% have irregular bleeding in 1st 3m
Usually settles
Use lowest oestrogen dose for cycle control
May need to increase from 20mcg to 30-35mcg
No evidence tricycling settles bleeding
Progesterone only
Bleeding pattern on one method does not predict bleeding
patterns with another method
FSRH - management of unscheduled
bleeding on hormonal contraception
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POP:
Early - 30% change in bleeding and 10% irregular
Later – 50% regular bleed and 30-40% irregular
No evidence changing type of pill will help
No evidence that 2 pills per day will help
Injectable:
35% amenorrhoeic at 3m and 70% at 1y
No evidence reducing interval improves bleeding
Mefenamic acid 500mg bd 5d reduced length of bleeding
episode. No long term effect.
FSRH - management of unscheduled
bleeding on hormonal contraception
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Implant:
At 6m 30% infrequent and 10-20% prolonged bleeding
Doxycycline may help but limited evidence
IUS:
Irregular, light or heavy in 1st 6m
65% have amenorrhoea or reduced bleeding at 1y
No evidence for treatment options
Injectable / Implant / IUS:
COC upto 3m (usual use or continuous) recommended if
not contraindicated
Summary
History
Consider examination
Consider investigation for infections
Modify hormonal contraception
Refer if persistant bleeding for 6-8 week
References
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Clinical practice guidance for the assessment of young women
aged 20-24 with abnormal vaginal bleeding. DoH Mar2010.
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalasset
s/@dh/@en/@ps/documents/digitalasset/dh_113553.pdf
Management of unscheduled bleeding in women using
hormonal contraception. FSRH May2009.
http://www.rcog.org.uk/files/rcogcorp/UnscheduledBleeding23092009.pdf
Persistant PCB. RCOG Query bank.
http://www.rcog.org.uk/womens-health/clinicalguidance/persistent-post-coital-bleeding-query-bank