Management of Abnormal Vaginal Bleeding Dr Jacqueline Guest, Consultant Obstetrician and Gynaecologist

Look at the problem in 4 different stages Post pubertal Middle reproductive life Perimenopausal Postmenopausal

Post pubertal Menarche in the UK is about 12.6 years It is genetically controlled Initiation of the process involves an interaction with the percentage body fat and genetics Early cycles are in the majority anovulatory May take 5-8 years before cycle normality is established The lack of ovulation and lack of production of progesterone leads to endometrial hyperplasia and thus heavy menstrual loss

“Metropathia haemorrhagica”

Post pubertal bleeding problems They are, for the vast majority of girls, self limiting Therefore, the most important thing in dealing with them is reassurance Consider von Willebrand screen

Suggested treatment plans: HB > 12g/l Reassurance HB 10-12g/l Cyclical progestogens (7, 14 or 21 days out of 28) provera 5mg bd day 7 (14 or 21) to 28 or norethisterone same schedule. Vary dose on side effects and response The Combined Contraceptive Pill eg microgynon 30 , triphasic if cycle control poor or loestrin 20 if s/e Suggest stopping these on an annual basis to see if the normal pattern has established

Suggested treatment plans: HB< 10g/l COC for a continuous period to correct anaemia, and then used cyclically after that Consider Implanon Wary of Depoprovera as peak bone mass not yet reached If none of these work, consider scan to exclude very rare uterine pathology (Beware TVS if not sexually active)

MIDDLE REPRODUCTIVE LIFE What is “abnormal”? PCB IMB Menorrhagia Oligo-amenorrhoea

Remember in this group of patients, exclude pregnancy and thus ectopic as a cause of irregular bleeding (Mole if follows a pregnancy)

Postcoital bleeding: causes Vaginal lesions (rare) Trauma Benign cervical lesions Polyps Cervical ectropion (OCP) Cervicitis: Chlamydia: PCB reported in 18% of women Malignant cervical lesions Check smear history Squamous carcinoma Adenocarcinoma

Intermenstrual bleeding: causes Normal: occurs in 1-2% of cycles periovulatory Exogenous hormones: COC (poor compliance) POP IUS Depoprovera* Implanon* IUD (premenstrual) Endometriosis (Pre and post menstrual) Uterine: Endometrial polyps Fibroids: submucous fibroids can present with IMB Endometritis and PID: Can cause but not frequently Dysfunctional uterine bleeding: most likely to cause irregular cycles with or without menorrhagia Endometrial and myometrial malignancy; uncommon but important *Do not refer until I year after DEPO or Implanon

Management of PCB and IMB History: age, frequency, contraceptive history, smears, sexual history Examination: Abdominal LOOK at the cervix (discharge, contact bleeding, tenderness, polyp) Other possible sites of bleeding FB or IUCD tail Investigations: Smear if indicated Consider chlamydia and other swabs Consider pipelle if familiar with it

Who should you refer? Persistent IMB and/or PCB without any unusual features Women with a friable erosion Women with PCB/IMB with an abnormal smear ? Women on hormonal therapy: Women on progestogenic methods only if the bleeding is excessively frequent or prolonged. Can try stopping (remember chlamydia)

From the gynaecologist’s view point Malignancy is rare in this group of women, but investigations are to exclude any serious causes. We may not necessarily treat the symptoms if all neg Examination Colposcopy only if abnormal smear or abnormal looking cervix Cervical biopsy (again only if looks suspicious) Ultrasound scan (endometrial polyps and fibroids) Endometrial biopsy (EB) Hysteroscopy if EB not possible or polyps seen

Pipelle Endometrial Biopsy

Menorrhagia

Menorrhagia Heavy bleeding defined as menstrual blood loss more than 80ml per cycle Often subjective May be caused by: Idiopathic Fibroids IUD (not the IUS) Pelvic infection (painful) Bleeding disorders

NICE definition of heavy menstrual bleeding (HMB) “Excessive menstrual blood loss which interferes with the woman’s physical, emotional, social and material quality of life, and which can occur alone or in combination with other symptoms.”

History taking, examination and investigations History needs to cover nature and any related symptoms that might suggest structural or histological abnormality If it does, (IMB, PCB, Pelvic pain, discharge), physical examination and other investigations should be performed (swabs, USS, consider pipelle in over 40s) If it does not, pharmaceutical Rx can be started FBC on all Thyroid testing ONLY when other signs and symptoms are present. Coagulation disorders only when HMB since menarche or a personal or family history to suggest such a cause.

Physical examination Should be carried out before: IUS fittings Investigations for structural abnormalities Investigations referred to a specialist For histological abnormalities NB. Women with fibroids that are palpable abdominally or who have intra-cavity fibroids and/or uterine length as measured at pipelle or USS >12cm should be offered referral

Investigations at secondary care History Abdominal examination Speculum Bi-manual examination Endometrial biopsy: Age >40, persistent IMB/PCB, treatment failure or ineffective treatment Ultrasound is first line to identify structural abnormalities Fibroids: need no.,size and location Hysteroscopy used if failed EB, scan not helpful and want to see exact location of fibroid

Treatment options: pharmaceutical Depends on patient choice and suitability so 1st, 2nd, 3rd debateable First line: The IUS Second line: Tranexamic acid 500mg-1gm tds-qds (3 cycles to see if helps) Anti-prostaglandins eg. mefanamic acid 500mg qds (3 cycles to see if helps, especially if pain a feature) COC Third line: NET, day 5-26 of cycle Injectable progestogens or implanon Other: GNRH analogues (longer than 6/12, add back HRT) but not really a long term option. May pre-date surgery

Treatment options: surgical Endometrial ablation First generation: Rollerball and TCRE Second generation: Novasure (Impedance) Thermal balloon MEA (Microwave) About 200 more!

Ablation techniques Used if menorrhagia impacting on life and no desire to conceive (? Sterilisation at same op) Can be used with small fibroids (<3cm) Larger submucosal fibroids can be resected using the resecting loop at the same procedure RCOG states that IUS and/or ablation technique should be performed before considering hysterectomy if the uterus is no bigger than 10cm utero-cervical length on pipelle sampling

Management of fibroids Uterine artery embolisation: For fibroids >3cm where there is an impact on the patient’s quality of life. The procedure preserves the uterus and avoids surgery Fertility is potentially retained, but problem of ovarian failure in over 45’s

Management of fibroids Myomectomy Severe impact on life, fibroid >3cm If submucosal, resect with resecting loop, followed by Rollerball (if fertility not an issue). Often uncomplicated If intramural or submucosal a laparotomy will be required Fertility potentially retained, but may be haemorrhage, adhesions, recurrence and infection. May also need hysterectomy if bleeds excessively

Hysterectomy for Fibroids Indicated for fibroids causing a severe impact on quality of life where the family is complete Patients should be aware that the operative risks are greater for hysterectomy for fibroids Route should be discussed, but vaginal hysterectomy may be difficult with large fibroids

Hysterectomy for Menorrhagia Total Not first line solely for HMB. Consider when: Other treatments have failed, are contra-indicated (or declined) Desire for amenorrhoea FULLY informed woman requests it No desire to retain uterus and fertility Sub-total ?LAVH

Hysterectomy for Menorrhagia Vaginal hysterectomy first line if able to do Laparoscopically assisted vaginal hysterectomy if other pelvic condition that requires abdominal inspection or if ovaries to be removed and no equipment or training to do vaginally Finally, open procedure which is often quicker but slower recovery for patient and risk of wound infection Above order is RCOG recommended

Risks

Removal of ovaries at hysterectomy Ovaries still produce androgens after the menopause Risk of ovarian CA lifetime is 1% After hysterectomy it is 0.1% Removal of ovaries gives you 1 more day of life compared to non-removal Even if you take them out, risk of ovarian CA remains in the peritoneum Although may be more difficult to remove afterwards, not a justification to do so Some have difficulties in finding effective hormone replacement NICE 2007 “Do not remove healthy ovaries”

Recommended reading www.nice.org.uk

Number of hysterectomies for menorrhagia from 1989-90 to 2002-3 in NHS trusts in England Reid, P. C et al. BMJ 2005;330:938-939 Copyright ©2005 BMJ Publishing Group Ltd.

Perimenopausal bleeding problems They are similar in causation to those who are post-pubertal. Investigations are as for HMB/IMB in those aged 45 and above Endometrial polyps are more common The difference is that the risks of malignancy are higher Cervix Hyperplasia (atypical) Endometrial CA The length of time for the problem to persist is obviously less!

Management of perimenopausal bleeding problems Reassurance if no pathology found HRT if bleeding problems associated with menopausal symptoms Cyclical progestogens, for 3 weeks out of 4. Eg. NET, Dydrogesterone or Provera The IUS

Advantages of the IUS Longer term solution Fewer systemic side effects compared to oral Rx (no increased risk of VTE) Can be used in fibroids as long as any submucosal only small Can be part of HRT Amenorrhoea welcomed at this stage of reproductive life, without the need for surgery

Post-Menopausal Bleeding - PMB 10% of cases of PMB will be caused by endometrial carcinoma The use of HRT has increased the uncertainty as to what constitutes unscheduled bleeding requiring referral for investigation Tamoxifen use has increased for breast cancer and is associated with a 3-6 fold increase in the risk of endometrial carcinoma

Referral - All women with PMB “The risk of endometrial cancer in non-HRT users complaining of PMB and in HRT users experiencing abnormal bleeding is sufficient to recommend referring patients for investigation”

What is “Abnormal” bleeding in women on HRT? Sequential regimes: Bleeding that is heavy or prolonged at the end of, or after, the progestogen phase Bleeding occurring at any time (BTB) Continuous Combined regimes:* Bleeding that occurs after the first 6 months of treatment Bleeding occurring after amenorrhoea has been established *Far more likely if started too early

“If referred to the gynaecologist, an examination is not always necessary” “However, examination by GP or practice nurse can alter the course of clinical management if it expedites referral on grounds of raised suspicion of a malignancy”

Investigation of PMB “Where sufficient local skills and capacity exist, TVS is the first-line procedure to identify which women with PMB are at higher risk of endometrial cancer”

Have not used any form of HRT for ≥ 1 years, OR; An endometrial thickness of ≤ 3mm can be used to exclude endometrial cancer in women who: Have never used HRT, OR; Have not used any form of HRT for ≥ 1 years, OR; Are using continuous combined HRT. Estimated pre-test risk of CA: 10% ≤ 3mm ≥ 3mm Post-test risk: 0.6-0.8% Post-test risk: 20-22%

An endometrial thickness of ≤ 5 mm can be used to exclude endometrial cancer in women using sequential HRT (or having used it in the last year) with unscheduled bleeding Estimated pre-test risk: 1-1.5% ≥ 5mm ≤ 5mm Post test risk: 2-5% Post test risk: 0.1-0.2%

TVS is poor at differentiating potential cancer from other tamoxifen induced thickening because of the distorted endometrial architecture associated with long term use of tamoxifen. Hysteroscopy with biopsy is preferable as the first line of investigation in women taking Tamoxifen who experience PMB

PMB in Tayside Weekly PMB Clinic Patients should be referred urgently and will be seen with in 2-3 weeks History, TVS, examination and endometrial pipelle biopsy as required Arrangements made for ‘soon’ hysteroscopy if increased endometrial thickness and biopsy not possible, or if polyp present Patients with unscheduled bleeding on HRT have a gynae dept scan and appointment in the menopause clinic

Hysteroscopy Indicated where endometrial biopsy not possible If scan suggests possible polyp ?If on Tamoxifen

Finally