Dr Kristina Naidoo Consultant Gynaecologist Menstrual Disorders Defining normality Defining problem Investigations Treatment Normal menstruation Most menstrual cycles 22 to 35 days Normal menstrual flow 3 to 7 days ID: 462702
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Slide1
How to manage menstrual disorders in general practice and when to refer to secondary care
Dr Kristina NaidooConsultant GynaecologistSlide2
Menstrual Disorders
Defining normalityDefining problemInvestigations TreatmentSlide3
Normal menstruation
Most menstrual cycles 22 to 35 daysNormal menstrual flow 3 to 7 days Most blood loss occurs within first 3 daysMenstrual flow amounts to 35ml*In general, most normal menstruating women use five or six pads or tampons per day.Slide4
Menarche/Menopause
Menarche average age 12.9
Anovulatory
cycles 80% in first year, 10% in 6
th
year
Menopause 42-58 (average 51)
Postmenopausal bleeding > 1 year after the last mensesSlide5
Symptoms of AUB
Heavy menstrual bleedingIntermenstrual bleeding (IMB)Postcoital bleeding (PCB)Irregular menstrual cyclePostmenopausal bleeding
+/-painSlide6
FIGO classification of Causes of AUB
(non-pregnancy)PALM-COEIN
P polyps
A
adenomyosis
L
leiomyoma
M malignancy & hyperplasia
C
coagulopathy
O
ovulatory
disorders
E endometrial causes
I iatrogenic
N not classifiedSlide7
When to refer
Suspected cancer- symptomsPCB lasting more than 4 weeks over 35 years
IMB persistent and unexplained
1 or more episodes of PMB and NOT on HRT
Persistent or unexplained PMB 6/52 after
cessation of HRT
Any unscheduled bleeding on Tamoxifen
NOT Repeated, unexplained PCBSlide8
When to refer
Suspected cancer- signsPalpable abdominal/pelvic mass not obviously fibroids/urinary or GI
Lesion on cervix suspicious of cancer
Unexplained vulval lump
Vulval bleeding due to ulcerationSlide9
Heavy Menstrual Bleeding
(HMB)Excessive menstrual blood loss which interferes with a woman's physical, social, emotional and/or material quality of life
It can occur alone or in combination with other symptomsSlide10
HMB
Blood loss is subjective30% women consider their bleeding to be excessiveHalf of these have a normal blood loss (<80ml)Women aged 30-49, 1:20 consults GP re HMB each yearHMB accounts for 12% of Gynae referrals
£7 million a year spent on prescriptions in primary care (2007)Slide11Slide12Slide13
Mirena LNG-IUS
Provided long-term use (at least 12 months anticipated)
Prevents endometrial proliferation.
Contraceptive.
Doesn't impact future fertility.
Unwanted outcomes: irregular bleeding that can last for six months; amenorrhoea;
progestogen
-related problems such as breast tenderness, acne and headaches; uterine perforation at insertion (1 in 100,000 chance).
As equally effective in improving quality of life and psychological well-being as hysterectomy.Slide14
Submucous fibroid and
Mirena IUSSlide15
Tranexamic acid
Oral antifibrinolytic .If no improvement, stop after three cycles.Unwanted outcomes: indigestion; diarrhoea; headache.
No increased risk of thrombosis. Cochrane review.
Dose: 500 mg tablets. 2 to 3 tablets (1-1.5g three to four times daily for three to four days. From onset of heavy bleeding.Slide16
NSAIDs
Commonly used: mefenamic acidReduce production of prostaglandin.If no improvement, stop after three cycles.Preferred over tranexamic acid in dysmenorrhoea.Unwanted outcomes: indigestion; diarrhoea; worsening of
asthma
Dose: mefenamic acid 500 mg tablets. 1 tablet three times daily during heavy bleeding.Slide17
COCPs
Prevent proliferation of the endometrium.Also act as a contraceptive.Do not impact future fertility.Unwanted outcomes: mood change; headache; nausea; fluid retention; breast tenderness; DVT; MI; CVA.Slide18
Oral progestogen
Commonly used: Norethisterone
Prevents proliferation of the
endometrium
.
Does not impact future fertility.
Dose: 15 mg daily on days 5-26 of the cycle.
Unwanted outcomes: weight gain; bloating; breast tenderness; headaches; acne; depression
.
A recent Cochrane Review showed that this regime of
progestogen
results in a significant reduction in menstrual blood loss but that women find the treatment less acceptable than intrauterine
levonorgestrel
.Slide19
Injected progestogen
Depot-medroxyprogesterone acetate
Prevents proliferation of the
endometrium
.
Contraceptive.
Does not impact on future fertility.
Unwanted outcomes: as for oral
progs
; weight gain; irregular bleeding; amenorrhoea; bone density loss.
Current guidance:
Use in adolescents as last resort.
Other women re-evaluate after 2 years, if significant risk factors for osteoporosis consider alternative.Slide20
When to refer
Suspicion from history of increased risk of pathology:E.g. family history of endometrial or colonic cancerInfertility/nulliparityObesity/diabetes Unopposed oestrogen therapy
PCOSSlide21Slide22Slide23Slide24Slide25
‘One stop’ Menstrual Dysfunction Clinic
Conventional pathway
‘One stop’ pathway
General
Gynaecology Clinic ?biopsy
‘One stop’ menstrual dysfunction clinic
Pelvic scan
Review, list for Day Case Hysteroscopy
Pre-operative
assessment clinic
Hysteroscopy
under GA
Follow-up
to plan managementSlide26
Outpatient Hysteroscopy
RCOG recommendation2012 favourable tariff Diagnosis of benign intrauterine pathologyTreatmentResection polyps, small fibroids, RPOCs
IUD retrievalSlide27
Conclusions
Reassurance re normal patterns of bleedingFull blood count -first line investigationLow threshold for pelvic scanning (TVS) Hormonal contraception for HMB
Red flag symptoms-> HSC205 pathway
Risk factors for endometrial pathology-> refer
early
‘One stop’
clinics advantageous