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Bleeding problems

May 2012 Judith ten Hof. Bleeding problems. Bleeding problems. Abnormal/dysfunctional Bleeding Regular monthly and heavy Regular monthly with intermenstrual bleeding Irregular periods Irregular bleeding Post coital bleeding Post menopausal bleeding

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Bleeding problems

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  1. May 2012 Judith ten Hof Bleeding problems

  2. Bleeding problems • Abnormal/dysfunctional Bleeding • Regular monthly and heavy • Regular monthly with intermenstrual bleeding • Irregular periods • Irregular bleeding • Post coital bleeding • Post menopausal bleeding • Unscheduled bleeding on contraceptives

  3. Terminology

  4. Heavy menstrual bleeding • 1/20 women consult GP every year • 1990’s at least 60% hysterectomy • NICE clinical guideline 44

  5. What’s ‘new’ • Terminology • Pharmaceutical treatments • Endometrial ablation procedures • Uterine artery embolisation • Increase minimal access procedures • National Heavy Menstrual Bleeding Audit

  6. Heavy Menstrual Bleedingin primary care • 50% patients received some treatment in primary care (reported 83% of hospitals) • No pts received treatment in primary care (37% of hospitals) • ‘Guidelines should be in place for direct referral to imaging services from primary care’ (RCOG standards). • GPs could refer directly to imaging services (99.1% of hospitals). • It was less common for GPs to be able to refer directly to pathology (42.7%) and other diagnostic procedures (21.8%). • Only one hospital said that GPs could not refer directly to any services. • (First annual report of the National Heavy Menstrual Bleeding Audit 2011)

  7. Heavy Menstrual Bleedingin secondary care • Additional investigations: • TV USS • Pipelle biopsy • Options: • Medication non hormonal • Hormonal • IUS • Endometrial ablation • Hysterectomy • Larger fibroids: • Embolisation • Hysteroscopic resection • Myomectomy • Hysterectomy

  8. Patterns of surgical treatment over time Figure 3.1 Number of surgical operations for women with HMB in English NHS trusts between 1 April 1997 and 31 December 2009

  9. Uterine cavity before and after endometrial ablation Novasure Thermal balloon

  10. Irregular bleeding • No guidance • History: • Irregular periods • likely hormonal problem: PCOS, anovulatory cycles • Regular periods with IMB: • IU abnormality/infection • Irregular constant bleeding : • Hormonal, abnormality/infection • Post coital bleeding • Post menopausal bleeding • Unscheduled bleeding on contraceptives

  11. Irregular bleeding in primary care • Bleeding calendar might be helpful • Pt age • Other symptoms • eg pelvic pain • Hormonal dysfunction hirsutism, galactorrhoea • Ovulation pain • Family history

  12. Irregular bleeding in primary care • BMI • Abdominal examination • Speculum and bimanual • Triple swabs • Pipelle (>40-45yrs) • USS

  13. Irregular bleeding in primary care • Depending on clinical suspicion of IU abnormality • Refer • Heavy and irregular bleeding perimenopausal consider hysteroscopy, EB +/- Mirena • Trial to regulate cycle with COCP/ cyclical progesterone

  14. Post-coital bleeding • Bleeding during or after sexual intercourse • More likely from vagina or cervix than endometrium • vaginal: • vaginitis • carcinoma - very rare • cervix: • ectropion • cervicitis • polyps • carcinoma - the most likely malignant cause of PCB • trauma • Can be a sign of serious underlying pathology and is the classical symptom of cervical carcinoma • Prevalence in large community surveys :0.7-9 percent • Can be referred urgently

  15. Post-coital bleeding Shapley, Br J Gen Pract. 2006 June 1; 56(527): 453–460.

  16. Post-coital bleeding in primary care • History • duration & frequency of symptoms • Smear history • Sexual • Use of contraceptives • Examination: • Speculum and pelvis • Triple swabs • Findings: • Atrophic vaginitis treat • Cervical polyp  avulse & histology • Swabs pos  treat & review after 6-8 wks • No suspicion cancer: • <25 refer gynae clinic • >25 refer colposcopy • With intermenstrual bleeding refer gynae clinic • Suspicious cervical cancer: urgent 2WW referral

  17. Post-menopausal bleeding • SIGN guideline 61, 2002 • Definition: • Vaginal bleeding > 12 months after LMP • Unscheduled/abnormal bleeding on HRT • On continuous combined/Tibolone: • >6mths of treatment • After amenorrhoea • On sequential regimens: • Heavy/prolonged after progestogen phase • Bleeding at any other time

  18. Post-menopausal bleeding • 5% of referrals to gynaecology • Can be symptom of abnormality: • Endometrial cancer present in 10% • Endometrialhyperplasia • Intra-uterine abnormality • Vaginal/Cervical problem egvaginitis, cervical polyp

  19. Post-menopausal bleeding • Riskfactors: • Age • HRT • Tamoxifen • Other: • hereditary cancer syndromes • obesity, BM, hypertension, PCOS • (Unopposed oestrogen exposure) Incidence of vaginal bleeding (per 1000) - - - - - - % endometrium carcinoma Age(yrs)

  20. TV ultrasound • Endometrium is thin post-menopausal • Thickness can be measured by TV USS • Treshold thickness depends on sensitivity and specificity Endometrial cancer on Tamoxifen

  21. Transvaginalultrasonographic (TVUS) evaluation of women with post-menopausal bleeding SIGN guideline 61, 2002

  22. Post-menopausal bleeding • Where indicated and patients on Tamoxifen: • Hysterospcopy + endometrial biopsy • Biopsy alone • Recurrent bleeding needs further investigation

  23. Post-menopausal bleeding in primary care • History: • duration & frequency of symptoms • Smear history • Use of HRT/ contraceptives • Examination: • Speculum and pelvis • ?pipelle • Triple swabs • Findings: • Atrophic vaginitis treat • Cervical polyp  avulse & histology • Swabs pos  treat & review after 6-8 wks • ?Access to ultrasound • Refer if symptoms not resolved • Suspicious/confirmed endometrial cancer: urgent 2WW referral

  24. Unscheduled bleeding on hormonal contraception • FSRH guidance May 2009 • Often due to contraceptive: • superficial bloodvessel fragility in endometrium • change in endometrial steroid response • angiogenic factors • Cancer rare

  25. Expected bleeding patterns

  26. Unscheduled bleeding on hormonal contraception • History: • Contraception method, duration and use • Other medication • Smear history • Risk STD • Bleeding pattern prior to contraception • Other symptoms: pain, dyspareunia, PCB • pregnancy

  27. Unscheduled bleeding on hormonal contraception • Examination if: • Persistent > first 3-6mths/ change in bleeding pattern) • Not in cervical screening • Failed medical treatment • Pt request • Speculum+ bimanual +/- pipelle • USS • Hysteroscopy + EB

  28. Unscheduled bleeding on hormonal contraception. Therapy • COCP • change to EE 35mcg • try different pill • POP • try different (no evidence that changing progesterone improves bleeding/ desogestrel is better) • No evidence double dose • Implants/depoprover/implant • Add COCP 30/35mcEE+levonorgestrel/norethisterone • No evidence reducing injection interval • Mefenamic acid for 5 days

  29. Case1: PD 26yrs • Reg heavy periods • Po, Female partner • Tired otherwise well • O/E inclgynae • Normal findings

  30. Case 2: JC 79 yrs • 1 episode red bloodloss on wiping • Menopause age 52. No discharge • Not sexually active • H/O Breast cancer • Examination by GP: • Speculum difficult vaginal atrophy • No abdo masses, cervix palpates normal • Single episode • H/O haemorrhoids • TV-USS: ET 3mm, small fibroid 16mm, nl ovaries

  31. Case 3 AA 50yrs • Ref: • Irregular menstrual cycle, heavy bleeding • USS: bulky ut, 23mm fibroid, ET 13mm, nlov • Cycle: 1x/2-3 mths, more heavy • IMB and spotting • No climacteric symptoms • Married sexually active, no pain • Smears up to date

  32. Case 4 CS, 23 yrs • Bleeding after sex • Implant in situ 2 yrs • Irreg small bleeds • Same partner 8mths • O/E • Cervix red and bleeds easily

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