IRREGULAR VAGINAL BLEEDING in a WOMAN BEFORE MENOPAUSE

1. Max Brinsmead PhD FRANZCOG July 2011 IRREGULAR VAGINAL BLEEDING in a WOMAN BEFORE MENOPAUSE

2. The common causes are… • Pregnancy-related • Miscarriage – threatened, inevitable or incomplete • Ectopic • Cervical Bleeding • Benign • Ectropion, Cervicitis or Polyp • Cancer of the cervix • Rare in patients who have regular Pap smears) • Bleeding from the uterine cavity • Benign • Fibroids and Polyps • Cancer • Dysfunctional uterine bleeding • A diagnosis made after excluding other causes

3. But also keep in mind… • Hormones that have been given • Depoprovera (or DMP or DMPA) • Oral contraceptives (COC) • Other (some OTC drugs affect cycles) • Bleeding disorders • Rare • Usually associated with other bleeding or bruising

4. When a patient complains about abnormal vaginal bleeding... • First determine if she has: • Regular but heavy or prolonged periods • This is called menorrhagia • It is a common manifestation of fibroids • Rarely due to a bleeding disorder • Regular periods with bleeding at other times • If the bleeding is postcoital it should be regarded as cancer of the cervix until proven otherwise • Irregular bleeding • This may be dysfunctional uterine bleeding but this diagnosis is can only made when other causes are excluded • And always exclude pregnancy • Best done by pregnancy test

5. Consider your patient’s age… • If the patient is young (<40 years) • Endometrial cancer is uncommon • But Ca cervix always needs to be ruled out • If the patient is very young & never sexually active • Pregnancy, STD and Ca cervix never occurs • But dysfunctional uterine bleeding is not uncommon • If the patient is >45 years • Cancer from within the uterine cavity can only be excluded by endometrial biopsy or curette • Check also for Ca cervix • But dysfunctional bleeding is not uncommon

6. You must always examine… • Look for signs of anaemia • Examine the abdomen to see if there is a uterus or other mass arising out of the pelvis • Pass a speculum and decide if the bleeding is coming from or through the cervix • Look carefully at the cervix • Examine the pelvis bimanually to see if the uterus is enlarged • (And if the cervix feels normal even if it looked abnormal)

7. Tests you should perform • FBC to check HB & platelet count • Pap smear if not recently performed • But this is not a test for cervical cancer! • Cervical or 1st voided urine for Chlamydia if the patient is at risk of STD • Ultrasound of the uterus has a limited role • But should be performed if the uterus is enlarged • It is NOT a substitute for clinical examination

8. Dysfunctional Uterine Bleeding (DUB) • There is often a history of missed periods or irregular cycles • May be associated with obesity and hirsutism (PCO Disorder) • Bleeding is usually painless • Unless there is clot colic • Bleeding can be very heavy or quite prolonged • There is a normal cervix and the uterus is not enlarged

9. Management of Abnormal Vaginal Bleeding • Antibiotics are indicated only for proven STI • Bleeding from an abnormal cervix is rarely a life-threatening emergency • But it generally requires referral for further testing and treatment • Transfusion should be reserved for those with severe anaemia and in whom you cannot immediately control the bleeding • Uterine bleeding after the age of 45 requires referral for D&C or biopsy • Dysfunctional uterine bleeding can be treated with oral hormone therapy (Progestin or COC)

10. Management of Dysfunctional Uterine Bleeding • Bleeding can be controlled with Norethisterone • Give 2x 5m tablets every 2 – 3 hours until the bleeding slows or stops • Then 5 mg BD for 10 – 14 days • The patient can then expect a “normal period” a few days after stopping the pills • Give COC in the next cycle • or Norethisterone 5 mg BD from day 10 – 25 of each cycle for 4 – 6 months • Give oral iron ± folate to treat anaemia

11. Emergency treatment of any Endometrial Bleeding • When the blood is coming through the cervix • Even if the patient is >45 years • Or if the uterus is enlarged by adenomyosis or fibroids • Or the patient has a bleeding disorder • You can try Norethisterone 10 mg every 2 – 3 hours • But refer also for further Ix and Rx

12. Management of Hormone-related PV bleeding • Irregular PV bleeding with Depoprovera or COC is secondary to their effect on the endometrium • But make sure that the cervix is normal • Then try Norethisterone as per DUB regimen • Or give Premarin 1.25 mg 8 hourly • Or any COC one tablet 6 hourly • Or just give another injection of Depot Provera • An episode of bleeding can be shortened with Mefanamic acid 500 mg BD for 5 days