IRREGULAR VAGINAL BLEEDING in a WOMAN BEFORE MENOPAUSE

1. Max Brinsmead PhD FRANZCOG July 2010 IRREGULAR VAGINAL BLEEDING in a WOMAN BEFORE MENOPAUSE

2. The common causes are… • Pregnancy-related • Successful but threatening to miscarry • Unsuccessful & aborting • Retained products of conception • After normal pregnancy or miscarriage • Ectopic • Cervical Bleeding • Benign • Ectropion, Cervicitis or Polyp • Cancer of the cervix • Bleeding from the uterine cavity • Benign • Fibroids and Polyps • Cancer • Dysfunctional uterine bleeding

3. But also keep in mind… • Hormones that have been given • Depoprovera (or DMP or DMPA) • Oral contraceptives (COC) • Other • 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 usually 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 (<35 years) • Cancer is uncommon • 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 >40 years • Cancer from within the uterine cavity can only be excluded by endometrial biopsy or curette • 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 • Examine the pelvis bimanually to see if the uterus is enlarged • (And if the cervix feels normal if it looked abnormal)

7. Dysfunctional Uterine Bleeding (DUB) • 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

8. Management of Abnormal Vaginal Bleeding • Antibiotics have no place nor role • Bleeding from an abnormal cervix is rarely a life-threatening emergency but it 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 40 requires referral for D&C • Dysfunctional uterine bleeding can be treated with Pills

9. Management of Dysfunctional Uterine Bleeding • Bleeding can be controlled with Norethisterone (5 mg tablets) • Give 2 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 iron & folate to treat anaemia

10. Emergency treatment of any Endometrial Bleeding • When the blood is coming through the cervix • Even if the patient is >40 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

11. 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 Depoprovera