ManagementOfAbnormalVaginalBleeding.ppt

management of abnormal vaginal bleeding,dr maggie thomson may 2009,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 percentages body fat and genetic determination of the age of onset early cycles are in the majority anovulatory may take 5-8 years before menstrual 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 they will come right in the end,suggested treatment plans:,hb 12g/l reassurance hb 10-12g/l cyclical progestogens (21 days out of 28) or the combined contraceptive pill suggest stopping these on an annual basis to see if the normal pattern has established hb 10g/l coc for a continuous period to correct anaemia, and then used cyclically after that 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 erosion cervicitis:,most importantly: chlamydia: pcb reported in 18% of women malignant cervical lesions squamous carcinoma adenocarcinoma,intermenstrual bleeding: causes (remember that imb and pcb are often indistinguishable),normal: occurs in 1-2% of cycles periovulatory exogenous hormones: coc (poor compliance) pop ius depoprovera* implanon* iud (premenstrual) endometriosis (pre and post menstrual),uterine: endometrial polyps (common cause) fibroids: submucous fibroids can present with imb 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 those on 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,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 (remember chlamydia in these!),from the gynaecologists view point,malignancy is very rare in this group of women, so investigations from our point of view are to exclude any serious causes, but not necessarily to treat the symptoms examination colposcopy only if abnormal smear or abnormal looking cervix cervical biopsy (again only if looks suspicious) ultrasound scan endometrial biopsy hysteroscopy if eb not possible or polyps seen,pipelle endometrial biopsy,menorrhagia,menorrhagia,heavy bleeding defined as menstrual blood loss more than 80ml 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 womans 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 and/or physical symptoms), physical and/or other investigations (us) should be performed. if it does, not pharmaceutical rx can be started initially 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 women with fibroids that are palpable abdominally or who have intra-cavitory fibroids and or uterine length as measured at us 12cm should be offered referral to a specialist,investigations at secondary care,history abdominal examination speculum bi-manual examination endometrial biopsy: age 45, persistent imb/pcb, treatment failure or ineffective treatment ultrasound is first line to identify structural abnormalities fibroids: need no.,size and location hysteroscopy used if failed eb, scan not helpful and want to see exact location of fibroid (d&c not to be used alone),treatment options: pharmaceutical,first line: the ius second line: transenamic acid (3 cycles if no help) anti-prostaglandins (3 cycles if no help) coc third line: net, day 5-26 of cycle injectable progestogens other: gnrh analogues (longer than 6/12, add back hrt),treatment options: surgical,endometrial ablation first generation: rollerball and tcre second generation: novasure (impedance) thermal balloon mea (microwave),ablation techniques,used if severe impact on life and no desire to conceive can be used with small fibroids (3cm) larger ones can be resected if submucosal with tcre preferable to hysterectomy if the uterus is no bigger than10-week pregnancy,management of fibroids,uterine artery embolisation: for fibroids 3cm, severe impact on quality of life and who want to retain uterus and avoid surgery fertility is potentially retained, but problem of ovarian failure in over 45s,management of fibroids,myomectomy severe impact on life, 3cm if submucosal, resect with tcre, followed by rollerball (if fertility not an issue) surgical myomectomy fertility potentially retained, but may be adhesions, recurrence and infection. may also need hysterectomy if bleeds,hysterectomy for fibroids,indicated for fibroids 3cm and severe impact on quality of life. patients should be aware that the operative risks are greater for hysterectomy for fibroids. route should be discussed, but may be difficult to do it vaginally with large fibroids.,hysterectomy for hmb,not first line solely for hmb. consider when: other treatments have failed, are contra-indicated or declined desire for amenorrhoea fully informed woman requests it no desire to retain uterus and fertility,total,subtotal,?lavh,risks,removal of ovaries at hysterectomy,nice 2007 “do not remove healthy 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 non-removal even if you take them out, risk of ovarian ca remains in the peritoneum although may be more difficult to remove afterwards, not a justification to do so always problems for some with ert,recommended reading .uk,copyright 2005 bmj publishing group ltd.,reid, p. c et al. bmj 2005;330:938-939,number of hysterectomies for menorrhagia from 1989-90 to 2002-3 in nhs trusts in england,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 the difference is that the risks of malignancy are much higher cervix hyperplasia (atypical) endometrial ca endometrial polyps are more common and: the length of time for the problem to persist is obviously less!,management of perimenopausal bleeding problems,reassurance if no pathology found hrt if bleeding problems associated with menopausal symptoms (femoston 2:20) cyclical progestogens, for 3 weeks out of 4. eg. net, provera and dydrogesterone the ius,advantages of the ius,longer term solution if required fewer systemic side effects compared to oral rx (no increased risk of vte) can be used in fibroids as long as not submucosal can be part of hrt amenorrhoea welcomed at this stage of reproductive life, without the need for surgery,pmb,10% of cases of pmb will be caused by ca endometrium the use of hrt has increased the uncertainty as to what constitutes unscheduled bleeding requiring referral for investigation tamoxifen use has increased for breast ca and is associated with a 3-6x fold increase in the risk of endometrial ca,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: may be heavy or prolonged at the end of or after the progestogen phase, or occur at any time (btb),continuous combined regimes:* it occurs after the first 6 months of treatment, or it occurs 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 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 first-line procedure to identify which women with pmb