1. Max Brinsmead MB BS PhD May 2015

2. The common causes are…  Pregnancy-related ○ Miscarriage – threatened, inevitable or incomplete ○ Ectopic  Cervical Bleeding Benign Ectropion, Cervicitis or Polyp Cancer of the cervix Rare in patients who have regular Pap smears)  Bleeding from the uterine cavity Benign Fibroids and Polyps Cancer Dysfunctional uterine bleeding A diagnosis made after excluding other causes

3. But also keep in mind…  Hormones that have been given ○ Depoprovera (or DMP or DMPA) ○ Oral contraceptives (COC) ○ Other (some OTC drugs affect cycles)  Bleeding disorders ○ Rare ○ Usually associated with other bleeding or bruising

4. When a patient complains about abnormal vaginal bleeding...  First determine if she has: ○ Regular but heavy or prolonged periods This is called menorrhagia It is a common manifestation of fibroids Rarely due to a bleeding disorder ○ Regular periods with bleeding at other times If the bleeding is postcoital it should be regarded as cancer of the cervix until proven otherwise ○ Irregular bleeding This may be dysfunctional uterine bleeding but this diagnosis is can only made when other causes are excluded  And always exclude pregnancy Best done by pregnancy test

5. Consider your patient’s age…  If the patient is young (<40 years) ○ Endometrial cancer is uncommon ○ But Ca cervix always needs to be ruled out  If the patient is very young & never sexually active ○ Pregnancy, STD and Ca cervix never occurs ○ But dysfunctional uterine bleeding is not uncommon  If the patient is >45 years ○ Cancer from within the uterine cavity can only be excluded by endometrial biopsy or curette ○ Check also for Ca cervix ○ But dysfunctional bleeding is not uncommon

6. You must always examine…  Look for signs of anaemia  Examine the abdomen to see if there is a uterus or other mass arising out of the pelvis  Pass a speculum and decide if the bleeding is coming from or through the cervix  Look carefully at the cervix  Examine the pelvis bimanually to see if the uterus is enlarged ○ (And if the cervix feels normal even if it looked abnormal)

7. Tests you should perform  FBC to check HB & platelet count  Pap smear if not recently performed But this is not a test for cervical cancer!  Cervical or 1 st voided urine for Chlamydia if the patient is at risk of STD  Ultrasound of the uterus has a limited role But should be performed if the uterus is enlarged It is NOT a substitute for clinical examination

8. Dysfunctional Uterine Bleeding (DUB)  There is often a history of missed periods or irregular cycles  May be associated with obesity and hirsutism (PCO Disorder)  Bleeding is usually painless Unless there is clot colic  Bleeding can be very heavy or quite prolonged  There is a normal cervix and the uterus is not enlarged

9. Management of Abnormal Vaginal Bleeding  Antibiotics are indicated only for proven STI  Bleeding from an abnormal cervix is rarely a life-threatening emergency But it generally requires referral for further testing and treatment  Transfusion should be reserved for those with severe anaemia and in whom you cannot immediately control the bleeding  Uterine bleeding after the age of 45 requires referral for D&C or biopsy  Dysfunctional uterine bleeding can be treated with oral hormone therapy (Progestin or COC)

10. Management of Dysfunctional Uterine Bleeding  Bleeding can be controlled with Norethisterone  Give 2x 5m tablets every 2 – 3 hours until the bleeding slows or stops  Then 5 mg BD for 10 – 14 days  The patient can then expect a “normal period” a few days after stopping the pills  Give COC in the next cycle  or Norethisterone 5 mg BD from day 10 – 25 of each cycle for 4 – 6 months  Give oral iron ± folate to treat anaemia

11. Emergency treatment of any Endometrial Bleeding  When the blood is coming through the cervix  Even if the patient is >45 years  Or if the uterus is enlarged by adenomyosis or fibroids  Or the patient has a bleeding disorder  You can try Norethisterone 10 mg every 2 – 3 hours  But refer also for further Ix and Rx

12. Management of Hormone-related PV bleeding  Irregular PV bleeding with Depoprovera or COC is secondary to their effect on the endometrium  But make sure that the cervix is normal  Then try Norethisterone as per DUB regimen Or give Premarin 1.25 mg 8 hourly Or any COC one tablet 6 hourly Or just give another injection of Depot Provera An episode of bleeding can be shortened with Mefanamic acid 500 mg BD for 5 days

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