Abnormal Uterine Bleeding Martin DeBono & Lisa Pickles (consultant, O&G) (GP)

NICE guidance: Heavy Menstrual Bleeding 2007. Be aware of this – complements our guidance.

ABNORMAL UTERINE BLEEDING 1/ Menorrhagia 2/ Irregular Bleeding 3/ Postmenopausal Bleeding 2a <40years old 2b >40 years old

ABNORMAL UTERINE BLEEDING 1/ Menorrhagia 2/ Irregular Bleeding 3/ Postmenopausal Bleeding 2a <40years old 2b >40 years old

1/ Menorrhagia- summary of guidelines. Regular, heavy bleeds with normal examination, no need for hysteroscopy. Treatment options: - TXA, MFA, COC - Mirena - Depo provera Refer GYNAECOLOGY OPD if all options fail (to discuss surgical management)

Surgical Treatments for Menorrhagia. Normal uterus +/- small fibroids <3cm diameter Other treatments failed. No desire to retain uterus. Fibroids >3cm diameter. Normal uterus +/- small fibroids <3cm diameter. Hysterectomy (vaginal if poss.) Endometrial ablation. Treat the Fibroid Myomectomy Uterine artery embolisation

ABNORMAL UTERINE BLEEDING 1/ Menorrhagia 2/ Irregular Bleeding 3/ Postmenopausal Bleeding 2a <40years old 2b >40 years old

2/ Irregular Bleeding – summary of guidelines. 2a/ <40years UNLIKELY to need hysteroscopy. Causes: Contraception? Infection? Cervix? PCOS? 2b/ > 40years MAY need hysteroscopy(expanded on next slide) Causes: Malignancy? Perimenopause? HRT?

2b/ > 40years old (irregular bleeding) Work out SIGNIFICANCE of bleeding. Significant IMB Continual spotting No recognisable cycle Not significant No IMB Period-like flow Recognisable periods, even if irregular, short or long cycle. Hysteroscopy Observe then? hysteroscopy

ABNORMAL UTERINE BLEEDING 1/ Menorrhagia 2/ Irregular Bleeding 3/ Postmenopausal Bleeding 2a <40years old 2b >40 years old

ABNORMAL UTERINE BLEEDING 1/ Menorrhagia 2/ Irregular Bleeding 3/ Postmenopausal Bleeding 2a <40years old 2b >40 years old

Risk factors for endometrial carcinoma. Remember these : Obesity PCOS Diabetes Hypertension. Infertility/nulliparous Tamoxifen Early menarche/late menopause. FH ca colon/emdometrium

ABNORMAL UTERINE BLEEDING 1/ Menorrhagia 2/ Irregular Bleeding 3/ Postmenopausal Bleeding 2a <40years old 2b >40 years old

3/ PMB – summary of guidelines URGENT referral DAPH. ( Direct Access Programmed Hysteroscopy. May have transvaginal scan for endometrial thickness. If >4mm then hysteroscopy).

Notes re DAPH for problem bleeding 1 referral urgency Urgent < 2 weeks post menopausal bleeding high suspicion of uterine cancer, eg suspicious examination, multiple risk factors for endometrial Ca with significant bleeding. Soon Perimenopausal bleeding – significant (see earlier descriptors) Routine 13 week Normal examination Perimenopausal, persistent, not significant bleeding 2 contraindications to hysteroscopy Pregnancy, Recent PID, Cervical pathology (refer to Colposcopy OPD)

Abnormal vaginal bleeding Case Quiz When to refer for hysteroscopy

50 year old. Cycle heavy 5-7/20-35. Answer a/ no action or medical management b/refer hysteroscopy c/other (assume normal exam,swabs,smear, preg test etc unless otherwise stated) 1/. 50 year old. Cycle heavy 5-7/20-35.

35 year old with menorrhagia (no IMB). Answer a/ no action or medical management b/refer hysteroscopy c/other (assume normal exam,swabs,smear, preg test etc unless otherwise stated) 2/. 35 year old with menorrhagia (no IMB). Not responded to medical management including mirena coil.

30year old with heavy periods and mid cycle bleeding Answer a/ no action or medical management b/refer hysteroscopy c/other (assume normal exam,swabs,smear, preg test etc unless otherwise stated) 3/. 30year old with heavy periods and mid cycle bleeding

45 year old.Regular cycle 5/28. Answer a/ no action or medical management b/refer hysteroscopy c/other (assume normal exam,swabs,smear, preg test etc unless otherwise stated) 4/. 45 year old.Regular cycle 5/28. LMP started after 21 day cycle, now spotting or brownish loss for 5 weeks since then.

Cycle regular 6/26-30 with spotting in between for past 6/12. Answer a/ no action or medical management b/refer hysteroscopy c/other (assume normal exam,swabs,smear, preg test etc unless otherwise stated) 5/. 41 year old. Cycle regular 6/26-30 with spotting in between for past 6/12.

LMP-flooding for 2 days, normal loss for 3 days, then stopped Answer a/ no action or medical management b/refer hysteroscopy c/other (assume normal exam,swabs,smear, preg test etc unless otherwise stated) 6/. 49 year old. Cycle 5-7/28-56 for past year. LMP-flooding for 2 days, normal loss for 3 days, then stopped

LMP started after 28 day cycle, flooding for 2 days and now spotting, Answer a/ no action or medical management b/refer hysteroscopy c/other (assume normal exam,swabs,smear, preg test etc unless otherwise stated) 7/. 46 year old.Cycle 5-7/20-35. LMP started after 28 day cycle, flooding for 2 days and now spotting, brown loss , which has continued for 2 weeks.

55 year old with vaginal dryness. LMP 5 years ago. Answer a/ no action or medical management b/refer hysteroscopy c/other (assume normal exam,swabs,smear, preg test etc unless otherwise stated) 8/. 55 year old with vaginal dryness. LMP 5 years ago. Atrophia on examination. Reports brown/red streaky loss for 3 months on and off.

Reports a period for 5 days. Answer a/ no action or medical management b/refer hysteroscopy c/other (assume normal exam,swabs,smear, preg test etc unless otherwise stated) 9/. 52 year old. LMP 14 months ago. Reports a period for 5 days.

GREY AREAS 1/ 37 year old, obese, diabetic, PCOS, with IMB. Assume normal exam, swabs, smear, preg test etc unless stated 1/ 37 year old, obese, diabetic, PCOS, with IMB.

GREY AREAS 2/ 52 year old. Had period 9/04. 2/06. Assume normal exam, swabs, smear, preg test etc unless stated 2/ 52 year old. Had period 9/04. 2/06. Seen 6/06 when above symptoms reported.

GREY AREAS 3/ 84 year old with vaginal dryness, LMP 25 years ago. Assume normal exam, swabs, smear, preg test etc unless stated 3/ 84 year old with vaginal dryness, LMP 25 years ago. OE/ atrophia. Reports brown/red loss on and off for 3 months.

GREY AREAS 4/ 41 year old. Regular menorrhagia. Hb=9.1 (microcytic). Assume normal exam, swabs, smear, preg test etc unless stated 4/ 41 year old. Regular menorrhagia. Hb=9.1 (microcytic).

Comments 1/ Place of ultrasound? 2/ Norethisterone ? In menorrhagia. ? In irregular bleeding.

Comments – contd: 3/ Anaemia ? Refer or not. 4/ Adnexal mass & irregular bleeding: -?urgent hysteroscopy -? 2 week gynae cancer referral

Summary/key messages Regular menorrhagia does not usually need hysteroscopy. In over 40s, think about SIGNIFICANCE of irregular bleeding: significant – IMB, not recognisable as period (refer) not significant – No IMB, period-like flow (may not need referral). PMB needs urgent DAPH (may have US scan)

?? QUESTIONS??

References. Nice Guidance: Heavy menstrual bleeding. January 2007. Abnormal Vaginal Bleeding – primary care pathway, Calderdale. Find this on Pennine website. ( www.pennine-gp-training.co.uk ). March 2007.