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Inter Menstrual Bleeding

Inter Menstrual Bleeding. Dr. Soniya Mathew 01/12/2010. Aims. Definition Causes Assessment Management Referral. Definition. Bleeding from the vagina At any time in the menstrual cycle Other than normal menstruation

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Inter Menstrual Bleeding

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  1. Inter Menstrual Bleeding Dr. Soniya Mathew 01/12/2010

  2. Aims • Definition • Causes • Assessment • Management • Referral

  3. Definition • Bleeding from the vagina • At any time in the menstrual cycle • Other than normal menstruation • Variable amount of bleeding • Regular menstrual periods • Not metrorrhagia (Irregularly frequent periods)

  4. Causes • Pregnancy related • Ectopic pregnancy • Gestational trophoblastic disease • Physiological • Around ovulation (Spotting – 2%) • Iatrogenic • Hormonal contraception • Tamoxifen • Following smear or treatment to cervix • C-section scars • Drugs

  5. Causes • Vaginal • Adenosis • Vaginitis • Tumours • Cervical • Infection • Cancer • Cervical polyps • Cervical ectropion • Condyloma acuminata of the cervix

  6. Causes • Uterine • Endometrial polyps • Cancer • Adenomyosis • Endometritis • Fibroids • Oestrogen secreting ovarian cancers

  7. Assessment • History • Menstrual • Obstetric • Gynaecological • Sexual • Medical • Current medications

  8. Assessment • Examination • Rule out rectal/ urethral bleeding • BMI • Abdominal examination • Pelvic examination • Ectropion • Polyp • Cervicitis

  9. Cervical ectropion

  10. Management • Investigations • Pregnancy test • Infection screen • Blood tests • FBC, Clotting screen, TFT, FSH/LH • Transvaginal USS • If persistent IMB (More than 3/12) • Ideally, immediate post menstrual • Endometrial biopsy • > 45 years • After first 3/12 of starting a contraception

  11. Management • Infection • Antibiotics + contact tracing • Hormonal contraception • Monitor for bleeding • < 45 yrs and no clinical findings and no risk factors: Reassurance • May try different hormonal contraception

  12. Management • Ectropion • Stop COCP • Conservative vs. cauterisation • Thermal cautery/ diathermy/ cryosurgery/ laser/ microwave therapy • Polyp • Avulsion + histology • Further investigations, if > 45 yrs

  13. Referral • Urgent referral • Suspected cervical cancer on examination • Persistent IMB and negative clinical examination • USS not available, in the presence of non-specific palpable mass • Referral for USS • Palpable abdominal/ pelvic mass, not obviously uterine fibroids/ gastro or urological in origin.

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