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

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

3. 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

4. “Metropathia haemorrhagica”

5. 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

6. 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

7. 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)

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

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

10. 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

11. 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

12. 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

13. 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)

14. 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

15. Pipelle Endometrial Biopsy

16. Menorrhagia

17. 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

18. 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.”

19. 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.

20. 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

21. 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

22. 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

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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. Risks

31. 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”

32. Recommended reading

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

35. 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!

36. 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

37. 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

39. 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

40. 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”

41. 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

42. “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”

43. 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”

44. 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: %
Post-test risk: 20-22%

45. 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: %

46. 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

47. 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

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

49. Finally