1. Abnormal uterine bleeding
Miss Roopa Nair
Consultant Gynaecologist

2. Objectives Menstrual disorders Intermenstrual and postcoital bleeding
Postmenopausal bleeding
Prepubertal not in scope
GP teaching 9/5/17

3. Menstrual disorders Menorrhagia Polymenorrhoea Polymenorrhagia
Oligomenorrhoea
DUB
GP teaching 9/5/17

4. HMB
Heavy menstrual bleeding should be defined as 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(NICE) 20% GOPD referrals
GP teaching 9/5/17

5. FIGO PALM-COEIN Coagulopathy Polyps Ovulatory dysfunction Adenomyosis
Endometrial
Iatrogenic
Not yet classified
Polyps
Adenomyosis
Leiomyoma
Malignancy and hyperplasia
GP teaching 9/5/17

6. Classification system including leiomyoma subclassification system
Classification system including leiomyoma subclassification system. Reprinted from Int J Gynaecol Obstet, 113(1), Munro MG, Critchley HO, Broder MS, Fraser IS; FIGO Working Group on Menstrual Disorders. FIGO classification system (PALM‐COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Pages 3–13, Copyright 2011, with permission from Elsevier.
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The Obstetrician & Gynaecologist Volume 19, Issue 2, pages , 25 JAN 2017 DOI: /tog
GP teaching 9/5/17

7. GP teaching 9/5/17

8. Management of HMB HISTORY EXAMINATION Menstrual history
Nature of bleeding/IMB/PCB
Pelvic pain/dyspareunia
Pressure symptoms
EXAMINATION
GP teaching 9/5/17

9. Investigations FBC S.FSH Coagulation screen Hormonal profile
S.ferritin
S.FSH
Hormonal profile
Thyroid function tests
GP teaching 9/5/17

10. Investigations Pipelle biopsy Imaging: USS/MRI Hysteroscopy
GP teaching 9/5/17

11. GP teaching 9/5/17

12. Non surgical Treatment of HMB
Tranexamic acid
Mefenamic acid
COC
Progestogens-oral
Progestogens-injectable
LNG-IUS(Mirena)
GP teaching 9/5/17

13. Dysmenorrhoea, also reduces bleeding
Tranexamic acid
Antifibrinolytic inhibits conversion of plasminogen to plasmin, reduces bleeding
mg qds during periods
Mefenamic acid
NSAID
Dysmenorrhoea, also reduces bleeding
Can be used as long as benefits the woman
Stop after 3 cycles if no benefit
GP teaching 9/5/17

14. Regularises cycles, reduces bleeding Contraception desired
COC
Regularises cycles, reduces bleeding
Contraception desired
Among First line in reproductive age group if no contraindications
Oral progestogens
NET/Provera from D5-D26 of cycle
Do not use only in luteal phase
Injectable progestogens
Depoprovera every 13 weeks
Amenorrhoea, irregular spotting
Contraceptive
Weight gain
Bone density concerns in adolescents/perimenopause
GP teaching 9/5/17

15. Mirena (Levonorgestrel IUS) 52 mg; 20 mcg per day
Thinning of endometrium
Amenorrhoea, irregular spotting
Contraceptive
Persevere atleast 6 cycles
5 years
GP teaching 9/5/17

16. Order of therapy When no structural or histological abnormality
Tranexamic acid if desires to conceive
If fertility not desired
Mirena
COC
Oral progestogens D5-D26
Injectable progesterone
GP teaching 9/5/17

17. Surgical treatment Endometrial ablation Hysterectomy
GP teaching 9/5/17

18. Endometrial ablation
Destroys functionally active endometrial glands located in the endomyometrial junction and upto 5 mm of myometrium
Completed family, no desire for future fertility
Uterus less than 10 weeks size, HMB alone
Less invasive than hysterectomy
GP teaching 9/5/17

19. Endometrial ablation First generation :Hysteroscopic -TCRE
-Rollerball endometrial ablation
Second generation: Non hysteroscopic
-Novasure(Impedance controlled radiofrequency)
-Thermachoice(Fluid filled balloon thermal ablation)
-Hydrothermal ablation
-Microwave endometrial ablation(MEA)
GP teaching 9/5/17

20. RF ablation(Novasure)
Treatmet time 90 secs Cervical dilatation to 8 mm cavity check
GP teaching 9/5/17

21. Fibroids: Medical management
Ullipristal(Esmya)
Preop-GnRHa
> 3cm+HMB
GP teaching 9/5/17

22. GnRH analogues
Prior to surgery for fibroids ( to reduce fibroid size and facilitate surgery)
On its own when other options including UAE and surgery contraindicated
Prolonged use more than 6 months needs add-back therapy
Menopausal symptoms
Zoladex 3.6 mg sc/im
GP teaching 9/5/17

23. Esmya Ulipristal acetate
Selective progestogen receptor modulator(SPRM)
Licenced for Emergency contraception 2009/Fibroids 2012
5mg daily 3 months
Upto 4 courses
2 bleeds between courses
GP teaching 9/5/17

24. Surgical options for fibroids
UAE
Myomectomy
Hysterectomy
Research settings
MR guided laser
MR guided focused ultrasound
GP teaching 9/5/17

25. Uterine artery embolisation
Women with HMB and fibroids who wish to retain fertility/preserve uterus
Dysmenorrhoea/pressure symptoms
Pretreatment with GnRH analogues contraindicated due to effect on blood vessels
Pretreatment with Esmya may be suitable
GP teaching 9/5/17

26. Myomectomy Preservation of fertility Hysteroscopic resection
Laparoscopic myomectomy
Open myomectomy
GP teaching 9/5/17

27. Hysterectomy Not first line(NICE) Consider when:
Other treatment options have failed or are contraindicated
No desire for future fertility or to retain uterus
Desires amenorrhoea
Full discussion with woman including risks
GP teaching 9/5/17

28. Hysterectomy Vaginal Laparoscopic route Open abdominal Subtotal
Removal of ovaries
GP teaching 9/5/17

29. IMB and PCB
Intermenstrual bleeding (IMB) is vaginal bleeding at any time other than during normal menstruation or following intercourse
Post coital bleeding (PCB) is non-menstrual vaginal bleeding that occurs immediately after intercourse (Newson, 2014; RANZCOG, )
IBM and PCB are not diagnoses but symptoms that necessitate further assessment.
GP teaching 9/5/17

30. Causes of PCB Infection
Cervical ectropion-especially in those taking COCP
Cervical or endometrial polyps
Trauma
Cervical cancer-usually apparent on speculum examination
In about 50% of cases no specific cause of bleeding is found (Sahu, Latheef, Aboel Magd, 2007)
GP teaching 9/5/17

31. Causes of IMB
Pregnancy related including ectopic & gestational trophoblastic disease
Physiological
Spotting around ovulation (1-2%)
Hormonal changes during perimenopause (diagnosis of exclusion)
Vaginal
Adenosis
Vaginitis (bleeding uncommon before the menopause)
Tumours
Cervical
Infection-chlamydia and gonorrhoea
Cancer (although usually PCB)
Cervical polyps
Cervical ectropion
Condylomata acuminate of cervix
GP teaching 9/5/17

32. Oestrogen secreting ovarian cancers
Uterine
Fibroids
Endometrial polyps
Cancer (endometrial adenocarcinoma, adenosarcoma and leiomyosarcoma)
Endometritis
Adenomyosis
Oestrogen secreting ovarian cancers
Iatrogenic
Tamoxifen
Following smear or treatment to cervix
Missed oral contraceptive pills
Drugs altering clotting parameters e.g. anticoagulants, SSRIs, corticosteroids
Alternative remedies when taken with hormonal contraceptives e.g. ginseng, ginko, soy supplements and St. Johns wort.
GP teaching 9/5/17

33. GP teaching 9/5/17

34. PMB Bleeding after one year of absent periods(menopause)
Causes(Novak etal 2011)
Endometrial/cervical polyps 2-12%
Endometrial hyperplasia 5-10%
Endometrial carcinoma 10%
Exogenous estrogens %
Atrophic endometritis and vaginitis 60-80%
GP teaching 9/5/17

35. PMB 10% risk of Endometrial carcinoma 2ww pathway
Needs USS and hysteroscopic evaluation if ET>5mm
MDT discussion
GP teaching 9/5/17

36. GP teaching 9/5/17