Abnormal Vaginal Bleeding

1. Abnormal Vaginal Bleeding

2. Objectives

3. Poll Question What is the average blood loss during a typical menstrual cycle? • 20 cc • 40 cc • 60 cc • 80 cc

4. Case Study 1 Case Study #1 What should be the first question(s) on your mind?

5. Check for hypotension, tachycardia, orthostasis, fever, ill appearance. LMP, contraception, menopause, hysterectomy • Early pregnancy bleeding may be life-threatening • Many women unaware of pregnancy • Always consider her to be pregnant and rule that out first • Urine test detects pregnancy 2 wks after conception • Serum test detects about 1 wk after conception • All clinics caring for women should have point-of-care (on-site) urine pregnancy tests; urine results faster, newer tests highly accurate Remaining assessment points discussed later.

6. Hemodynamically Stable? NO  urgent evaluation

7. Pregnant? POSITIVE PREGNANCY TEST  Urgent evaluation

8. Poll Answer What is the average blood loss during a typical menstrual cycle? • 20 cc • 40 cc • 60 cc • 80 cc Now we’ll explore normal menses, including average blood loss.

9. Increased cervical mucus secretions at mid-cycle • Premenstrual symptoms (cramps, breast tenderness, bloating, appetite/mood changes) • Heavy blood loss is >80 ml per cycle

10. Menstrual Cycle • First part of cycle: • Estrogen dominant  endometrium builds • Ovulation occurs 14 days before onset of the next period • After ovulation, corpus luteum is formed and creates progesterone. • Second part of cycle: • Progesterone dominant  endometrium is stabilized

11. Correlation Between Cycle Duration and Bleeding • Shorter intervals between cycles  endometrium has less time to proliferate  shorter duration of bleeding • Longer intervals between cycles  endometrium proliferates  longer periods of bleeding

12. Back to the case of our 42 yo veteran with onset “heavy” vaginal bleeding and cramping Why does heavy bleeding occur?

13. What Causes Ovulatory Bleeding?

14. Structural lesions can cause regular, heavy bleeding • Fibroids or other lesions that are in or near the lining, in particular, can cause heavy bleeding • Fibroids usually cause regular, heavy bleeding but can also cause intermenstrual bleeding • Other lesions, such as polyps, or even inflammation and infection can also cause heavy bleeding • Endometritis (infection in the uterine lining, is particularly prevalent during post-partum or post-procedure periods Uterine Lesions

15. What Causes Anovulation andAnovulatory Bleeding?

16. In normal menstrual cycle, endometrial lining builds up with estrogen and stabilizes with progesterone • If ovulation doesn’t occur, progesterone isn’t produced • Thus, endometrium continues to build, isn’t stabilized, and begins to slough off • A woman might experience irregular bleeding which can be heavy or light Anovulation Menstrual Cycle

17. Hemodynamic Stability Back to the case… Pregnancy 42-year-old veteran What more should you ask?

18. Ask about abdominal or pelvic pain: • Related to menstrual cramps that have worsened with increased flow? • Something serious like an ectopic pregnancy (with a positive pregnancy test)? • Query pain duration, constant or cyclical, location (midline or lateral), sudden onset or gradual • Ask about menstruation patterns • What is normal for her? • History of irregular/heavy menses? • Ask about other symptoms: • Related to anemia: shortness of breath, light-headedness, syncope, fatigue • Related to infection: fever, chills

19. Estimating Blood LossTry to obtain objective evidence • For triage, try to quantify bleeding by number of pads the woman is using, or ask her to compare it with her normal menses. • Typical definition of profuse bleeding: soaks large sanitary pad or tampon every hour or two, for two or more hours • Prolonged uterine bleeding = bleeding for >7 days • For diagnosis, pad/tampon counts are unreliable. Studies show 50% of women complaining of heavy bleeding have normal blood loss. • Estimates of blood loss taken by history are not reliable, though you may get a sense of changes in pattern. CBC and ferritin can help figure out if she has ongoing, significant blood loss, but these may be normal in a patient with acute blood loss only.

20. Our 42 yo veteran with onset “heavy” vaginal bleeding… It was decided that she should be seen by the provider

21. Exam Room Set-Up • Specifics about room set-up and assisting during the exam is covered in another session, but in general, necessary equipment includes: • Table with foot rests, privacy curtain, lockable door • Gown and cover sheet • Gloves for provider and assistant • Surgical lubricant • Speculum appropriate for patient: Graves (small, med, large) or Pederson • Light source • Supplies for Pap and GC/chlamydia tests • Procto swabs (also known as fox swabs) • Monsels /silver nitrate sticks if recent gynecological procedure • Pad / panty liner / tissues for post-procedure • Female chaperone is required; assistant may be used in this role • Privacy

22. Further Evaluation Nurses are often asked to explain at least the basics of pelvic US and endometrial biopsy procedures…

23. What is it? Test to look at organs and structures in the pelvis. How is it done? An instrument called a “transducer” sends out sound waves that bounce off body structures like an echo to create a picture. A clear gel, placed between the transducer and pelvis, allows smooth movement of the transducer over skin and eliminates air between the skin and transducer to improve sound conduction. A typical US exam takes 30-60 minutes. Risks? No radiation exposure. Usually painless, but may cause some mild discomfort as the transducer is guided over a full bladder. Pelvic Ultrasound Transabdominal Image used with permission from Krames StayWell

24. What is it? Test to look at reproductive organs. How is it done? Probe is inserted into vagina. It is covered with a condom and surgical lubricant. Probe sends out sound waves that bounce off body structures to create a picture. What are you looking for? Abnormal findings, such as fibroids. Thickness of the endometrial stripe. Risks? No radiation exposure. Generally painless, but pressure from probe could be uncomfortable. Patients with vaginal atrophy/ dryness might be uncomfortable. Pelvic Ultrasound Transvaginal Photo source: Krames Image used with permission from Krames StayWell

25. Endometrial Biopsy • When is it recommended? • For abnormal bleeding…heavy or prolonged…generally women >40 • What are you looking for? • Cause of abnormal bleeding • Checking for endometrial cancer (very accurate for diagnosing endometrial cancer) • What are potential complications? • Are rare; generally a very safe procedure • Infection, bleeding, cramping • Perforation of the uterus What is an endometrial biopsy? Tissue is taken from uterine lining (endometrium) and checked in pathology for abnormal or malignant cells. How is it done? Office-based, no sedation, typically pre-medicate with an NSAID Patient will be lying down with feet in foot rests. Provider will insert speculum to visualize the cervix. Cervix is cleaned with antiseptic and then grasped with a tenaculum to stabilize the uterus. Cervical dilator may be used to open cervical canal if there is stenosis. Small, hollow, plastic tube is gently passed into uterine cavity. Gentle suction removes sampling of the lining. Patient might be taken to OR for HSC, D&C with anesthesia. However, office procedures are safe, and a decrease in morbidity and mortality from D&C has been noted since office-based endometrial biopsies were introduced.

26. Endometrial Biopsy Image used with permission from Krames StayWell

27. Back to our 42 yo veteran with “heavy” vaginal bleeding…… Whether or not fibroids are causing the heavy bleeding is not certain – it could be just changes in her cycle as she approaches the perimenopausal years.

28. Poll Question Vaginal bleeding in a woman with a new positive pregnancy test may be due to: • Threatened abortion • Incomplete spontaneous abortion • Ectopic pregnancy • Vaginal laceration/abrasion • All of the above

29. Case Study 2 What are ALWAYS your two primary triage concerns?

30. Is she hemodynamically stable? • Is she pregnant? • After establishing status of her hemodynamic stability and pregnancy, you can move on to a more detailed pain assessment, assessment of her menstrual patterns, other symptoms, and estimated blood loss. • Note that this evaluation follows the same steps as the evaluation for the previous patient.

31. Case Study 2 Continued….

32. What Diagnoses Do You Need to Have in Mind?

33. Causes of First Trimester Bleeding

34. Poll Answer Vaginal bleeding in a woman with a new positive pregnancy test may be due to: • Threatened abortion • Incomplete spontaneous abortion • Ectopic pregnancy • Vaginal laceration/abrasion • All of the above

35. Back to the case of our 33 yo Veteran with irregular vaginal bleeding… Next steps for evaluation

36. Poll Question Does recurrent bleeding or spotting between periods require further evaluation? • Yes • No

37. Case Study 3 What are possible causes?

38. Causes of Intermenstrual Bleeding Many of these may be evident on exam, so a complete H&P is the next step.

39. Poll Answer Does recurrent bleeding or spotting between periods require further evaluation? • Yes • No As we have just reviewed, physiologic bleeding is a diagnosis of exclusion. Therefore, a pelvic exam with cervical cancer screening is the MINIMUM evaluation this patient will need. Likely that she will need additional evaluation beyond that.

40. Case Study 4 What questions should you ask?

41. Emphasis is a bit different when assessing postmenopausal women… with vaginal bleeding • Pregnancy • Less concern about pregnancy as women get older • HOWEVER, if patient is still menstruating, there is a chance she could be pregnant… we have seen pregnancy in women who are in their early 50’s • Hemodynamic stability • Difficult to assess hemodynamic stability over the phone • HOWEVER, this patient reported small amounts of bleeding. If indeed there is little bleeding, hemodynamic instability is less of a concern.

43. Postmenopausal Bleeding Possible Causes

44. Primary goal of evaluating postmenopausal bleeding is to exclude malignancy Different approach may be used for patients on hormone replacement therapy

45. Key Points for Vaginal Bleeding