PV Bleeding: a case presentation John Alabi GPST323/10/12

History 26 yr old afro-caribbean lady; M.W 26 yr old afro-caribbean lady; M.W ‘Golden minute’ – “Dr. I’m getting married this weekend and will be going away to dubai for my honeymoon. I feel my period might coming during this time and I was hoping to delay it.” ‘Golden minute’ – “Dr. I’m getting married this weekend and will be going away to dubai for my honeymoon. I feel my period might coming during this time and I was hoping to delay it.” “I would like some medication to stop the period till I get back!” “I would like some medication to stop the period till I get back!”

History Heavier periods over last 6 cycles Heavier periods over last 6 cycles Progressively worsening Progressively worsening Tired; but not thought much about it “with planning a wedding and all!!” Tired; but not thought much about it “with planning a wedding and all!!”

Negatives Fever, N+V Fever, N+V SOB/CP SOB/CP Palpitations Palpitations Abdominal distension Abdominal distension Vaginal discharge Vaginal discharge Dyspareunia Dyspareunia Bowel habit Bowel habit

History Intentionally lost weight for wedding 5kg Intentionally lost weight for wedding 5kg Some frequency but no dysuria Some frequency but no dysuria Occassional low backpain Occassional low backpain Periods are getting more painful than before. Periods are getting more painful than before.

PMHx – nil PMHx – nil Drug Hx. – nil Drug Hx. – nil NKDA NKDA Non-smoker Non-smoker Alcohol – occassional Alcohol – occassional Family Hx – Father (Hypertension), Sister (Hysterectomy) Family Hx – Father (Hypertension), Sister (Hysterectomy)

Obstetric Hx: Nulliparous Obstetric Hx: Nulliparous Sexually active; single partner for 5 yrs Sexually active; single partner for 5 yrs No previous STI No previous STI On COCP (microgynon 30) On COCP (microgynon 30)

Gynae Hx Menarche = 13 yr Menarche = 13 yr LMP = 3wks ago LMP = 3wks ago K = 5 days (now slightly extending day 6) K = 5 days (now slightly extending day 6) Cycle = 28 – 30 days Cycle = 28 – 30 days

Initial examination JACCOL – negative JACCOL – negative Cadiovascularly stable Cadiovascularly stable

Management Time up for sessions Time up for sessions Agreed to come back in following honeymoon for examination Agreed to come back in following honeymoon for examination Bloods requested – FBC, E+U, LFT, TFT, Coag screen Bloods requested – FBC, E+U, LFT, TFT, Coag screen Urinalysis Urinalysis Advised to omit pill free period and take COCP ‘back to back Advised to omit pill free period and take COCP ‘back to back Discussed afterwards with trainer. Discussed afterwards with trainer.

Results Urinalysis – negative Urinalysis – negative Bloods; Hb – 10.2g/dl otherwise normal Bloods; Hb – 10.2g/dl otherwise normal Notes; no hx of cervical smear Notes; no hx of cervical smear

Exam Abdo – full. Soft. Non-tender Abdo – full. Soft. Non-tender Supra-pubic fullness. About week size uterus Supra-pubic fullness. About week size uterus Bimanual exam - 14week enlarged, firm and irregular uterus. Adnexae are normal Bimanual exam - 14week enlarged, firm and irregular uterus. Adnexae are normal Cervical smear – cervix appeared normal. taken with permission Cervical smear – cervix appeared normal. taken with permission

Management Pelvic ultrasound shows an enlarged uterus with irregular contour and multiple intramural masses consistent with uterine fibroids. Both ovaries are visualized and normal Pelvic ultrasound shows an enlarged uterus with irregular contour and multiple intramural masses consistent with uterine fibroids. Both ovaries are visualized and normal She has been referred to a gynaecologists and we await further info. She has been referred to a gynaecologists and we await further info.

NICE 2007 HMB; excessive menstrual blood loss interfering with quality of life, or objectively as loss of > 80ml per menstrual period HMB; excessive menstrual blood loss interfering with quality of life, or objectively as loss of > 80ml per menstrual period Initial assesment – Hx, FBC, and if structural or histological abnormailty suspected. Initial assesment – Hx, FBC, and if structural or histological abnormailty suspected. USScan if uterus is palpable USScan if uterus is palpable Consider biopsy to exclude Ca if; (1) persistent IMB (2) age > 45yrs (3) failed or ineffective tx Consider biopsy to exclude Ca if; (1) persistent IMB (2) age > 45yrs (3) failed or ineffective tx

NICE 2007 Mirena IUS – 1 st line Mirena IUS – 1 st line Tranexamic acid or NSAIDs – stop after 3cycles if no improvement Tranexamic acid or NSAIDs – stop after 3cycles if no improvement COCP COCP Progestrogen – norethisterone 5mg (day 5-26 of cycle) or as Depo-provera Progestrogen – norethisterone 5mg (day 5-26 of cycle) or as Depo-provera GnRH analogue GnRH analogue If 1 st line fail; consider a 2 nd drug option, consider pelvic exam +/- if not already done If 1 st line fail; consider a 2 nd drug option, consider pelvic exam +/- if not already done

NICE 2007 Endometrial ablation – if no desire to conceive and fibroids are <3cm Endometrial ablation – if no desire to conceive and fibroids are <3cm Hysterectomy – no desire to retain uterus or fertility but wants amenorrhoea Hysterectomy – no desire to retain uterus or fertility but wants amenorrhoea Uterine artery embolization – if fibroids >3cm. Consider as 1 st line if significant symptoms like pain or pressure. Potentially retains fertility Uterine artery embolization – if fibroids >3cm. Consider as 1 st line if significant symptoms like pain or pressure. Potentially retains fertility Myomectomy - >3cm. Potentially retains fertility Myomectomy - >3cm. Potentially retains fertility

review of Systematic medical and surgical tx of HMB: clinical evidence 2012:01:805 NSAIDs and Tranexamic acid (used individually). Good evidence that both are efftive, resulting in significantly less mean bloodloss than placebo NSAIDs and Tranexamic acid (used individually). Good evidence that both are efftive, resulting in significantly less mean bloodloss than placebo Tranexamic acide vs. NSAIDs: poor quality evidence but 2 RCT favour tranexamic acid Tranexamic acide vs. NSAIDs: poor quality evidence but 2 RCT favour tranexamic acid Poor quality evidence favouring one NSAID over another Poor quality evidence favouring one NSAID over another Danazol – was found to be effective & leads to less bloodloss than NSAIDs and oral progestrogens Danazol – was found to be effective & leads to less bloodloss than NSAIDs and oral progestrogens Few trials comparing COC, oral luteal phase progestogens, IUS and GNRH analogues Few trials comparing COC, oral luteal phase progestogens, IUS and GNRH analogues COC – similar efficacy to NSAIDs COC – similar efficacy to NSAIDs Mirena – 1 RCT; more effective in reducing bloodloss than luteal phase progestogen at 6mths, and more than COC at 1yr Mirena – 1 RCT; more effective in reducing bloodloss than luteal phase progestogen at 6mths, and more than COC at 1yr PO progestrogens- less effective than tranexamic acid and danazol but may be as effective as NSAIDs PO progestrogens- less effective than tranexamic acid and danazol but may be as effective as NSAIDs

Hysterectomy – definetely effective han other medical or surgical tx. 1/3 experience comlications but fewer womer overall are dissatisfied Hysterectomy – definetely effective han other medical or surgical tx. 1/3 experience comlications but fewer womer overall are dissatisfied Endometrial destruction techniques –hysteroscopic laser ablation, non- hysteroscopic balloon/microwave ablation). also effective. Complications includes infction, perforation, haemorrhage Endometrial destruction techniques –hysteroscopic laser ablation, non- hysteroscopic balloon/microwave ablation). also effective. Complications includes infction, perforation, haemorrhage Ullipristal acetate – (NEJM 2012) participants took daily x 3mths resulting in control of bleeding in 90% of women, ¾ eporting rapid amennorhoea. Further studies needed to see it s effect on the endometrium as the drug causes some characteristic changes Ullipristal acetate – (NEJM 2012) participants took daily x 3mths resulting in control of bleeding in 90% of women, ¾ eporting rapid amennorhoea. Further studies needed to see it s effect on the endometrium as the drug causes some characteristic changes

Conclusion Tranexamic acid or NSAIDs Tranexamic acid or NSAIDs Tranexamic acid now available otc as cyklo-F or femstrual Tranexamic acid now available otc as cyklo-F or femstrual COC also confers contraceptive benefits COC also confers contraceptive benefits Surgical options: less invasive and effective methods are available depending on local availability and individual choice but hysterectomy is definitive Surgical options: less invasive and effective methods are available depending on local availability and individual choice but hysterectomy is definitive

Any questions?

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