Approach to Abnormal Uterine Bleeding in - PowerPoint Presentation

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Approach to Abnormal Uterine Bleeding in General Practice

Dr. Lubna Qayam

Outline

Causes

Approach

Management

Scenario 1

A 32 year old lady P2 c/o spotting in between her periods, post coital bleeding with regular periods which lasts for 4-6 days, mild dysmenorrhoea, no dyspareunia. There is no significant medical history. There was a h/o STI in past which was treated successfully and she is in stable relationship for

5

years. She takes CHC.

Scenario 2

A 48 year old lady P2 with a h/o normal and regular periods in past. She is c/o irregular periods with prolonged bleeding pattern lasting for 5-9 days for 6-8 months . No post coital or intermenstrual bleeding. She had an USS done recently showing ET 2.5 mm with normal ovaries. Her recent blood tests are normal. She uses condoms as contraception.

Scenario 3

4. A

25-year-old woman who has been using the progestogen-only implant presents

with irregular

bleeding since starting 7 months ago and would like treatment or for it to be removed. She

has no

significant medical history. After consideration and exclusion of other factors, what is

the appropriate

treatment to offer her

?

Scenario 4

3. A

37-year-old woman who has had the

levonorgestrel

-releasing intrauterine system (LNG-IUS)

for 9

months complains about the irregular spotting she has always experienced with this

method. She

wishes to control the bleeding while on holiday. She has no contraindications to

hormonal contraceptives

.

Causes of AUB

AUB

Reproductive AgePALM-COIEN

Post Menopausal

PALM: structural causesPolyps,pregnancy AdenomyosisLeiomyomaMalignany and hyperplasia

COEIN: Non structuralCoagulopathyOvulatory dysfunctionEndometrialItrogenic( tamoxifen, HC, anticoagulants, herbel meds, steroids)Not yet classifiedHyperthyroid (21%)Hypothyroid (23%)

Causes of AUB

AUB

Anovulatory -Just after menarche-perimenopausal-Hypothalamo-pituitary axis disturbance-Unoppsed Estrogen absence of progesterone results in unpredictable, irregular and prolonged bleeding patternse.g.PCOS, thyroid, ^prolactin

Ovulatory - Menorrhagia with regular periods

How to approach

History:

age, Menstrual

H

x

, Sexual

Hx

, Obstetric/

Gynae

Hx

Past medical

Hx

Drug

Hx

Family

Hx

Examination: systemic illness, galactorrhoea, A

Nigricans

,

hirsuitism

, Acne,

Abdo

, PS, PV

Investigations

: Exclude pregnancy, Swabs for STI, Check recent

Cx

screening result, Blood test( FBC, Clotting, TFT, LFTs), USS pelvis

Treatment:

Treat the cause

Treatment of Anovulatory bleeding

Progestogens like Nor-

Ethisterone

or medroxyprogesterone

To arrest the heavy bleeding

Then cyclically

COC pills for 3-6 months

Treatment of heavy menstrual bleeding (Menorrhagia)

If women is not wishing for contraception or while waiting for the Investigations/if fibroid is less than 3 cm

Mefanemic

acid with Tranexamic acid is the 1

st

choice

If Long term contraception is acceptable then

LNG-IUS is the 1

st

choice

2

nd

Choice

COC that reduces

dysmennorhoea

and regulate cycles

3

rd

Choice

Nor-

e

thisterone

day 5-26 ( not effective contraception, but may inhibit ovulation)or Depo-

provera

12 weekly

GNRH

analougues

Not recommended in PC, but a good option in SC

Treatment of Menorrhagia

If initial 1

st

line Rx fails then combine

Tranexamic acid +

Nsaids

(dysmenorrhoea)

Nsaids

+

COCpills

To arrest heavy bleeding

NEST 5mg- 10mg

tds

for 10 days ( stops bleeding with in 1-3 days, with drawl bleed occurs 2-4 d after stopping Rx)

REFERRALS:

Alarm symptoms

QOL is negatively affected by menorrhagia

Women wishes to have surgery

Fe deficiency anaemia that fails to respond to pharmaceutical treatment

Problematic bleeding with hormonal contraception

It is

challenging. For many

women it is

due to

the contraceptive

method

itself

Women

may consider that the

contraceptive and

non-contraceptive benefits of a method outweigh the inconvenience of

unpredictable bleeding

.

Assessment should be by

● C

linical

history

● Exclude

STI

- perform speculum exam and take swabs at least for chlamydia

● Check cervical screening history

● Consider the need for a pregnancy test

● Exclude underlying pathology

Medical Therapy options for women using hormonal contraception with problematic Bleeding

CHC users

 Reassurance for 1st 3 M , increase EE up to max 35micrograms

POP users  may try a different POP,

E

strogen

supplementation or tranexamic acid

PO implants,

injectibles

and IUS EE 30-35

micr

with LNG/

norethisterone

or

mefanemic

acid 500mg

tds

with tranexamic acid 1gm

qds

as s short term therapy.

Causes of Post Menopausal Bleeding

Atrophic vaginitis 60-80 %

HRT 15-25%

Polyps- endometrial or cervical 2-12%

Endometrial

hyperplasis

5-10%

Endometrial

carconima

10%

Estrogen

secreting ovarian tumours( Granulosa, Theca cell) <1%

Traumatic

e.g

ring pessary

Scenario 5

A 55 year old lady with an LMP 5 years ago presented with vaginal bleeding off and on. She is sexually active. She denies any medical history and does not take any OTC medications. O/E BP 142/88, BMI of 35, fresh bleeding in the vagina with a small blood clot on her right labia. Cervix looks healthy. Bimanual examination is satisfactory.

How will you proceed?

History

When?

Nature, precipitating factors like SI, Trauma

Discharge

HRT, tamoxifen, Anticoagulants

Any recent unintentional weight loss, fever,

abdo

pain, personal and family h/o endometrial, breast, ovarian / colon cancers, (LYNCH II) bladder bowel change

Parity

Age of menarche and menopause

Smoking HTN, DM

Last smear result

Examination

Vital signs

BMI

Signs of anaemia

Abdominal examination to assess the size, Contour, tenderness of uterus,

visceromegaly

, ascites.

Speculum examination – see vulva, vagina, signs of atrophy, bleeding, growths on vaginal wall/ cervix, abnormal discharge

Bimanual exam to look for size of uterus, mobility, fullness of adnexa and tenderness.

If suspected endometrial cause of bleeding, perform the

pipelle

biopsy and refer as 2WW ref to gynaecology.

Atrophic Vaginitis

Presents with soreness and dryness of vagina, vaginal bleeding,

supf

dyspareunia, dysuria

, recurrent UTI

and vaginal discharge

.

Thinning of the

vulval

and vaginal epithelium

Loss of glycogen

Fall in acidity

Absence of protective lactobacilli

Estriol

creams/ pessaries daily for 2 weeks then twice weekly for 3 months.(

Ovestin

,

Vagifem

,

Orthogynest

,

Premique

,

Prempak

)

No evidence that topical

E

strogens

causes endometrial proliferation

after 6-24 m of use therefore no need to prescribe systemic progestogens.

Vaginal lubricants can be use with or with out local

Estrogen

treatment.

PMB with HRT

Unscheduled Vaginal bleeding is a common adverse effect of HRT in first 3m of treatment.

CCHRT

- Commonly produces irregular breakthrough bleeding in first 4-6 m. Bleeding beyond 6m or after the spell of amenorrhoea requires further investigations. Once risk of malignancy is excluded then

try low dose

Estrogen

or ^ progesterone regimen.

Sequential HRT

should produce regular predictable bleeding starting towards or soon after the end of progesterone phase.

I

ncreasing the duration, dose or type of progestogen

is recommended.

References:

1. FSRH guidelines

2. Nice guidelines