Transcript PV Bleeding: a case presentation

PV Bleeding:
a case presentation
John Alabi
GPST3
23/10/12
History
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26 yr old afro-caribbean lady; M.W
‘Golden minute’ – “Dr. I’m getting married
this weekend and will be going away to dubai
for my honeymoon. I feel my period might
coming during this time and I was hoping to
delay it.”
“I would like some medication to stop the
period till I get back!”
History
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Heavier periods over last 6 cycles
Progressively worsening
Tired; but not thought much about it “with
planning a wedding and all!!”
Negatives
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Fever, N+V
SOB/CP
Palpitations
Abdominal distension
Vaginal discharge
Dyspareunia
Bowel habit
History
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Intentionally lost weight for wedding 5kg
Some frequency but no dysuria
Occassional low backpain
Periods are getting more painful than before.
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PMHx – nil
Drug Hx. – nil
NKDA
Non-smoker
Alcohol – occassional
Family Hx – Father (Hypertension), Sister
(Hysterectomy)
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Obstetric Hx: Nulliparous
Sexually active; single partner for 5 yrs
No previous STI
On COCP (microgynon 30)
Gynae Hx
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Menarche = 13 yr
LMP = 3wks ago
K = 5 days (now slightly extending day 6)
Cycle = 28 – 30 days
Initial examination
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JACCOL – negative
Cadiovascularly stable
Management
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Time up for sessions
Agreed to come back in following honeymoon
for examination
Bloods requested – FBC, E+U, LFT, TFT,
Coag screen
Urinalysis
Advised to omit pill free period and take
COCP ‘back to back
Discussed afterwards with trainer.
Results
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Urinalysis – negative
Bloods; Hb – 10.2g/dl otherwise normal
Notes; no hx of cervical smear
Exam
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Abdo – full. Soft. Non-tender
Supra-pubic fullness. About 12 -14 week size
uterus
Bimanual exam - 14week enlarged, firm and
irregular uterus. Adnexae are normal
Cervical smear – cervix appeared normal.
taken with permission
Management
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Pelvic ultrasound shows an enlarged uterus
with irregular contour and multiple intramural
masses consistent with uterine fibroids. Both
ovaries are visualized and normal
She has been referred to a gynaecologists and
we await further info.
NICE 2007
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HMB; excessive menstrual blood loss
interfering with quality of life, or objectively
as loss of > 80ml per menstrual period
Initial assesment – Hx, FBC, and if structural
or histological abnormailty suspected.
USScan if uterus is palpable
Consider biopsy to exclude Ca if; (1) persistent
IMB (2) age > 45yrs (3) failed or ineffective tx
NICE 2007
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Mirena IUS – 1st line
Tranexamic acid or NSAIDs – stop after
3cycles if no improvement
COCP
Progestrogen – norethisterone 5mg (day 5-26
of cycle) or as Depo-provera
GnRH analogue
If 1st line fail; consider a 2nd drug option,
consider pelvic exam +/- if not already done
NICE 2007
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Endometrial ablation – if no desire to conceive and
fibroids are <3cm
Hysterectomy – no desire to retain uterus or fertility
but wants amenorrhoea
Uterine artery embolization – if fibroids >3cm.
Consider as 1st line if significant symptoms like pain
or pressure. Potentially retains fertility
Myomectomy - >3cm. Potentially retains fertility
review of Systematic medical and surgical tx of HMB: clinical evidence
2012:01:805
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NSAIDs and Tranexamic acid (used individually). Good evidence that both are
efftive, resulting in significantly less mean bloodloss than placebo
Tranexamic acide vs. NSAIDs: poor quality evidence but 2 RCT favour tranexamic
acid
Poor quality evidence favouring one NSAID over another
Danazol – was found to be effective & leads to less bloodloss than NSAIDs and
oral progestrogens
Few trials comparing COC, oral luteal phase progestogens, IUS and GNRH
analogues
COC – similar efficacy to NSAIDs
Mirena – 1 RCT; more effective in reducing bloodloss than luteal phase
progestogen at 6mths, and more than COC at 1yr
PO progestrogens- less effective than tranexamic acid and danazol but may be as
effective as NSAIDs
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Hysterectomy – definetely effective han other medical or surgical tx. 1/3 experience
comlications but fewer womer overall are dissatisfied
Endometrial destruction techniques –hysteroscopic laser ablation, nonhysteroscopic balloon/microwave ablation). also effective. Complications includes
infction, perforation, haemorrhage
Ullipristal acetate – (NEJM 2012) participants took daily x 3mths resulting in
control of bleeding in 90% of women, ¾ eporting rapid amennorhoea. Further
studies needed to see it s effect on the endometrium as the drug causes some
characteristic changes
Conclusion
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Tranexamic acid or NSAIDs
Tranexamic acid now available otc as cyklo-F
or femstrual
COC also confers contraceptive benefits
Surgical options: less invasive and effective
methods are available depending on local
availability and individual choice but
hysterectomy is definitive
Any questions?
Thank you