Transcript Slide 1

Management of Abnormal
Vaginal Bleeding
Dr Jacqueline Guest,
Consultant Obstetrician and Gynaecologist
Look at the problem in 4
different stages
• Post pubertal
• Middle reproductive life
• Perimenopausal
• Postmenopausal
Post pubertal
Menarche in the UK is about 12.6 years
It is genetically controlled
Initiation of the process involves an interaction with the
percentage body fat and genetics
Early cycles are in the majority anovulatory
May take 5-8 years before cycle normality is established
The lack of ovulation and lack of production of
progesterone leads to endometrial hyperplasia and thus
heavy menstrual loss
“Metropathia haemorrhagica”
Post pubertal bleeding problems
 They are, for the vast majority of girls, self
limiting
 Therefore, the most important thing in
dealing with them is reassurance
 Consider von Willebrand
 screen
Suggested treatment plans:
 HB > 12g/l
 Reassurance
 HB 10-12g/l
 Cyclical progestogens (7, 14 or 21 days out of 28)
provera 5mg bd day 7 (14 or 21) to 28 or
norethisterone same schedule.

Vary dose on side effects and response
 The Combined Contraceptive Pill eg microgynon 30 ,
triphasic if cycle control poor or loestrin 20 if s/e
 Suggest stopping these on an annual basis to see if
the normal pattern has established
Suggested treatment plans:
 HB< 10g/l
 COC for a continuous period to correct anaemia, and
then used cyclically after that
 Consider Implanon
 Wary of Depoprovera as peak bone mass not yet
reached
 If none of these work, consider scan to exclude very rare
uterine pathology (Beware TVS if not sexually active)
MIDDLE REPRODUCTIVE
LIFE
What is “abnormal”?
PCB
IMB
Menorrhagia
Oligo-amenorrhoea
Remember in this
group of patients,
exclude pregnancy
and thus ectopic as
a cause of irregular
bleeding
(Mole if follows a
pregnancy)
Postcoital bleeding: causes
• Vaginal lesions (rare)
 Trauma




Benign cervical lesions
Polyps
Cervical ectropion (OCP)
Cervicitis:
Chlamydia: PCB reported in
18% of women
 Malignant cervical
lesions
 Check smear history
 Squamous carcinoma
 Adenocarcinoma
Intermenstrual bleeding: causes
• Normal: occurs in 1-2% of
cycles periovulatory
• Uterine:
 Endometrial polyps
•





 Fibroids: submucous fibroids
can present with IMB
Exogenous hormones:
COC (poor compliance)
POP
IUS
Depoprovera*
Implanon*
 IUD (premenstrual)
 Endometriosis (Pre and post
menstrual)
 Endometritis and PID: Can
cause but not frequently
 Dysfunctional uterine bleeding:
most likely to cause irregular
cycles with or without
menorrhagia
 Endometrial and myometrial
malignancy; uncommon but
important
*Do not refer until I year after DEPO or Implanon
Management of PCB and IMB
• History:
• age, frequency, contraceptive history, smears, sexual history
• Examination:
• Abdominal
• LOOK at the cervix (discharge, contact bleeding, tenderness, polyp)
• Other possible sites of bleeding
• FB or IUCD tail
• Investigations:
• Smear if indicated
• Consider chlamydia and other swabs
• Consider pipelle if familiar with it
Who should you refer?
Persistent IMB and/or PCB without any unusual
features
Women with a friable erosion
Women with PCB/IMB with an abnormal smear
? Women on hormonal therapy:
Women on progestogenic methods only if the
bleeding is excessively frequent or prolonged.
Can try stopping (remember chlamydia)
From the gynaecologist’s
view point
• Malignancy is rare in this group of women, but
investigations are to exclude any serious causes.
• We may not necessarily treat the symptoms if all neg
• Examination
• Colposcopy only if abnormal smear or abnormal
looking cervix
• Cervical biopsy (again only if looks suspicious)
• Ultrasound scan (endometrial polyps and fibroids)
• Endometrial biopsy (EB)
• Hysteroscopy if EB not possible or polyps seen
Pipelle Endometrial Biopsy
Menorrhagia
Menorrhagia
• Heavy bleeding defined as menstrual blood loss more
than 80ml per cycle
• Often subjective
• May be caused by:
 Idiopathic
 Fibroids
 IUD (not the IUS)
 Pelvic infection (painful)
 Bleeding disorders
NICE definition of heavy
menstrual bleeding (HMB)
• “Excessive menstrual
blood loss which
interferes with the
woman’s physical,
emotional, social and
material quality of life,
and which can occur
alone or in combination
with other symptoms.”
History taking, examination
and investigations
• History needs to cover nature and any related symptoms that might
suggest structural or histological abnormality
• If it does, (IMB, PCB, Pelvic pain, discharge), physical examination
and other investigations should be performed (swabs, USS,
consider pipelle in over 40s)
• If it does not, pharmaceutical Rx can be started
• FBC on all
•
Thyroid testing ONLY when other signs and symptoms are present.
•
Coagulation disorders only when HMB since menarche or a personal or family history
to suggest such a cause.
Physical examination
Should be carried out before:
• IUS fittings
• Investigations for structural abnormalities
• Investigations referred to a specialist
• For histological abnormalities
NB. Women with fibroids that are palpable
abdominally or who have intra-cavity fibroids
and/or uterine length as measured at pipelle or
USS >12cm should be offered referral
Investigations at secondary care
1.
History
2.
Abdominal examination
3.
Speculum
4.
Bi-manual examination
5.
Endometrial biopsy: Age >40, persistent IMB/PCB,
treatment failure or ineffective treatment
6.
Ultrasound is first line to identify structural
abnormalities
7.
Fibroids: need no.,size and location
8.
Hysteroscopy used if failed EB, scan not helpful and
want to see exact location of fibroid
Treatment options:
pharmaceutical
• Depends on patient choice and suitability so 1st, 2nd, 3rd debateable
• First line: The IUS
• Second line:
• Tranexamic acid 500mg-1gm tds-qds (3 cycles to see if helps)
• Anti-prostaglandins eg. mefanamic acid 500mg qds (3 cycles to see
if helps, especially if pain a feature)
• COC
• Third line:
• NET, day 5-26 of cycle
• Injectable progestogens or implanon
• Other: GNRH analogues (longer than 6/12, add back HRT) but not
really a long term option. May pre-date surgery
Treatment options: surgical
• Endometrial ablation
• First generation:
• Rollerball and TCRE
• Second generation:
• Novasure (Impedance)
• Thermal balloon
• MEA (Microwave)
• About 200 more!
Ablation techniques
• Used if menorrhagia impacting on life and no
desire to conceive (? Sterilisation at same op)
• Can be used with small fibroids (<3cm)
• Larger submucosal fibroids can be resected
using the resecting loop at the same procedure
• RCOG states that IUS and/or ablation technique
should be performed before considering
hysterectomy if the uterus is no bigger than
10cm utero-cervical length on pipelle sampling
Management of fibroids
• Uterine artery embolisation:
• For fibroids >3cm where there is an impact on the
patient’s quality of life. The procedure preserves the
uterus and avoids surgery
• Fertility is potentially retained, but problem of ovarian
failure in over 45’s
Management of fibroids
• Myomectomy
• Severe impact on life, fibroid >3cm
• If submucosal, resect with resecting loop, followed by
Rollerball (if fertility not an issue). Often uncomplicated
• If intramural or submucosal a laparotomy will be required
• Fertility potentially retained, but may be haemorrhage,
adhesions, recurrence and infection. May also need
hysterectomy if bleeds excessively
Hysterectomy for Fibroids
• Indicated for fibroids
causing a severe impact
on quality of life where the
family is complete
• Patients should be aware
that the operative risks
are greater for
hysterectomy for fibroids
• Route should be
discussed, but vaginal
hysterectomy may be
difficult with large fibroids
Hysterectomy for Menorrhagia
• Not first line solely for
HMB. Consider when:
Total
• Other treatments have
failed, are contra-indicated
(or declined)
• Desire for amenorrhoea
• FULLY informed woman
requests it
• No desire to retain uterus
and fertility
Sub-total
?LAVH
Hysterectomy for Menorrhagia
• Vaginal hysterectomy first line if able to do
• Laparoscopically assisted vaginal hysterectomy if other
pelvic condition that requires abdominal inspection or if
ovaries to be removed and no equipment or training to
do vaginally
• Finally, open procedure which is often quicker but slower
recovery for patient and risk of wound infection
• Above order is RCOG recommended
Risks
Removal of ovaries at
hysterectomy
• NICE 2007
• “Do not remove healthy
ovaries”
•
Ovaries still produce androgens
after the menopause
•
Risk of ovarian CA lifetime is 1%
•
After hysterectomy it is 0.1%
•
Removal of ovaries gives you 1
more day of life compared to nonremoval
•
Even if you take them out, risk of
ovarian CA remains in the
peritoneum
•
Although may be more difficult to
Recommended
reading
www.nice.org.uk
Number of hysterectomies for menorrhagia from 1989-90 to 2002-3 in NHS trusts in England
Reid, P. C et al. BMJ 2005;330:938-939
Copyright ©2005 BMJ Publishing Group Ltd.
Perimenopausal bleeding
problems
• They are similar in causation to
those who are post-pubertal.
• Investigations are as for
HMB/IMB in those aged 45 and
above
• Endometrial polyps are more
common
• The difference is that the risks
of malignancy are higher
 Cervix
 Hyperplasia (atypical)
 Endometrial CA
Management of perimenopausal
bleeding problems
• Reassurance if no
pathology found
• HRT if bleeding
problems associated
with menopausal
symptoms
• Cyclical progestogens,
for 3 weeks out of 4. Eg.
NET, Dydrogesterone or
Provera
• The IUS
Advantages of the IUS
• Longer term solution
• Fewer systemic side effects
compared to oral Rx (no
increased risk of VTE)
• Can be used in fibroids as
long as any submucosal
only small
• Can be part of HRT
• Amenorrhoea welcomed at
this stage of reproductive
life, without the need for
surgery
Post-Menopausal Bleeding - PMB
• 10% of cases of PMB will be caused by
endometrial carcinoma
• The use of HRT has increased the uncertainty as
to what constitutes unscheduled bleeding requiring
referral for investigation
• Tamoxifen use has increased for breast cancer
and is associated with a 3-6 fold increase in the
risk of endometrial carcinoma
Referral - All women with PMB
• “The risk of
endometrial cancer in
non-HRT users
complaining of PMB
and in HRT users
experiencing
abnormal bleeding is
sufficient to
recommend referring
patients for
investigation”
What is “Abnormal” bleeding in
women on HRT?
•
Sequential
regimes:
•
•
•
Bleeding that is heavy
or prolonged at the
end of, or after, the
progestogen phase
•
Bleeding occurring at
any time (BTB)
Continuous
Combined
regimes:*
•
Bleeding that occurs
after the first 6
months of treatment
•
Bleeding occurring
after amenorrhoea
has been established
*Far more likely if started too early
“If referred to the gynaecologist, an
examination is not always
necessary”
• “However, examination
by GP or practice
nurse can alter the
course of clinical
management if it
expedites referral on
grounds of raised
suspicion of a
malignancy”
Investigation of PMB
• “Where sufficient local
skills and capacity
exist, TVS is the firstline procedure to
identify which women
with PMB are at
higher risk of
endometrial cancer”
An endometrial thickness of ≤ 3mm can be used to
exclude endometrial cancer in women who:
•Have never used HRT, OR;
•Have not used any form of HRT for ≥ 1 years, OR;
•Are using continuous combined HRT.
Estimated pre-test risk of CA: 10%
≤ 3mm
Post-test risk: 0.6-0.8%
≥ 3mm
Post-test risk: 20-22%
An endometrial thickness of ≤ 5 mm can
be used to exclude endometrial cancer in
women using sequential HRT (or having
used it in the last year) with unscheduled
bleeding
Estimated pre-test risk: 1-1.5%
≥ 5mm
Post test risk: 2-5%
≤ 5mm
Post test risk: 0.1-0.2%
• TVS is poor at differentiating potential
cancer from other tamoxifen induced
thickening because of the distorted
endometrial architecture associated with
long term use of tamoxifen.
Hysteroscopy with biopsy is
preferable as the first line of
investigation in women taking
Tamoxifen who experience PMB
PMB in Tayside
• Weekly PMB Clinic
• Patients should be referred urgently and will be seen with in 2-3
weeks
• History, TVS, examination and endometrial pipelle biopsy as
required
• Arrangements made for ‘soon’ hysteroscopy if increased
endometrial thickness and biopsy not possible, or if polyp present
• Patients with unscheduled bleeding on HRT have a gynae dept scan
and appointment in the menopause clinic
Hysteroscopy
• Indicated where
endometrial biopsy
not possible
• If scan suggests
possible polyp
• ?If on Tamoxifen
Finally