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

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

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

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

5. 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)

8. 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

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

10. 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?

11. 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

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

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

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

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

20. 3/ PMB – summary of guidelines
URGENT referral DAPH.
( Direct Access Programmed Hysteroscopy. May have transvaginal scan for endometrial thickness. If >4mm then hysteroscopy).

22. 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)

23. Abnormal vaginal bleeding Case Quiz When to refer for hysteroscopy

24. 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.

25. 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.

26. 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

27. 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.

28. 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.

29. 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

30. 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.

31. 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.

32. 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.

33. 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.

34. 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.

35. 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.

36. 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).

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

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

39. 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)

40. ?? QUESTIONS??

41. References. Nice Guidance: Heavy menstrual bleeding. January 2007.
Abnormal Vaginal Bleeding – primary care pathway, Calderdale. Find this on Pennine website. ( ). March 2007.