1. Abnormal Vaginal Bleeding

2. VETERANS HEALTH ADMINISTRATION Objectives 2

3. VETERANS HEALTH ADMINISTRATION What is the average blood loss during a typical menstrual cycle? A.20 cc B.40 cc C.60 cc D.80 cc Question… 3

4. VETERANS HEALTH ADMINISTRATION Case Study #1 42-year-old Veteran “Heavy” vaginal bleeding for 3 days Some crampingMarried, 2 children What should be the first question(s) on your mind? Case Study 1 4

5. LMP, contraception, menopause, hysterectomy Early pregnancy bleeding may be life- threatening Many women unaware of pregnancy Always consider her to be pregnant and rule that out first ─Urine test detects pregnancy 2 wks after conception ─Serum test detects about 1 wk after conception ─All clinics caring for women should have point-of-care (on-site) urine pregnancy tests; urine results faster, newer tests highly accurate Check for hypotension, tachycardia, orthostasis, fever, ill appearance. Remaining assessment points discussed later.

6. VETERANS HEALTH ADMINISTRATION Hemodynamically Unstable? YES  urgent evaluation 6

7. VETERANS HEALTH ADMINISTRATION Pregnant? POSITIVE PREGNANCY TEST  Urgent evaluation 7

8. VETERANS HEALTH ADMINISTRATION Answer Now we’ll explore normal menses, including average blood loss. What is the average blood loss during a typical menstrual cycle? A.20 cc B.40 cc C.60 cc D.80 cc 8

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10. First part of cycle: Estrogen dominant  endometrium builds Ovulation occurs 14 days before onset of the next period After ovulation, corpus luteum is formed and creates progesterone. Second part of cycle: Progesterone dominant  endometrium is stabilized Menstrual Cycle

11. VETERANS HEALTH ADMINISTRATION Correlation Between Cycle Duration and Bleeding Shorter intervals between cycles  endometrium has less time to proliferate  shorter duration of bleeding Longer intervals between cycles  endometrium proliferates  longer periods of bleeding 11

12. VETERANS HEALTH ADMINISTRATION Back to the case of our 42 yo veteran with onset “heavy” vaginal bleeding and cramping. Why does heavy bleeding occur? 12

13. VETERANS HEALTH ADMINISTRATION What Causes Ovulatory Bleeding? Can be heavy, prolonged bleeding at regular intervals or intermenstrual bleeding Possible causes: Coagulopathy Neoplasm/malignancy Structural lesions (fibroids, polyps) Other (inflammation, infection like STI or endometritis) 13

14. VETERANS HEALTH ADMINISTRATION Uterine Lesions Structural lesions can cause regular, heavy bleeding Fibroids or other lesions that are in or near the lining, in particular, can cause heavy bleeding Fibroids usually cause regular, heavy bleeding but can also cause intermenstrual bleeding Other lesions, such as polyps, or even inflammation and infection can also cause heavy bleeding Endometritis (infection in the uterine lining, is particularly prevalent during post-partum or post-procedure periods 14

15. What Causes Anovulation and Anovulatory Bleeding? Primary hypothalamic-pituitary dysfunction Pituitary tumors and pituitary syndromes Stress, eating disorders, intense exercise Other endocrine problems Polycystic ovary syndrome Hyper- or hypothyroidism Medications Hormonal contraceptives Many other causes 15

16. In normal menstrual cycle, endometrial lining builds up with estrogen and stabilizes with progesterone If ovulation doesn’t occur, progesterone isn’t produced Thus, endometrium continues to build, isn’t stabilized, and begins to slough off A woman might experience irregular bleeding which can be heavy or light Anovulation 16

17. VETERANS HEALTH ADMINISTRATION Back to the case … 42-year-old veteran What more should you ask? Hemodynamic Stability Pregnancy 17

18. Ask about abdominal or pelvic pain: Related to worsening menstrual cramps with increased flow? Something serious like an ectopic pregnancy (with positive pregnancy test)? Query pain duration, constant or cyclical, location (midline or lateral), sudden onset or gradual Ask about menstruation patterns What is normal for her? History of irregular/heavy menses? Ask about other symptoms: Related to anemia: SOB, light- headedness, syncope, fatigue Related to infection: fever, chills 18

19. VETERANS HEALTH ADMINISTRATION Estimating Blood Loss Try to obtain objective evidence For triage, try to quantify bleeding by number of pads the woman is using, or ask her to compare it with her normal menses. − Typical definition of profuse bleeding: soaks large sanitary pad or tampon every hour or two, for two or more hours − Prolonged uterine bleeding = bleeding for >7 day s For diagnosis, pad/tampon counts are unreliable. Studies show 50% of women complaining of heavy bleeding have normal blood loss. Estimates of blood loss taken by history are not reliable, though you may get a sense of changes in pattern. CBC and ferritin can help figure out if she has ongoing, significant blood loss, but these may be normal in a patient with acute blood loss only. 19

20. VETERANS HEALTH ADMINISTRATION Our 42 yo veteran with onset “heavy” vaginal bleeding… Sexually active with husbandNo contraceptionRegular periods, 3 months of heavy bleedingNormal vital signs, appears well but worriedNegative pregnancy test; CBC, ferritin, TSH ordered It was decided that she should be seen by the provider 20

21. VETERANS HEALTH ADMINISTRATION Exam Room Set-Up Specifics about room set-up and assisting during the exam is covered in another session, but in general, necessary equipment includes: Table with foot rests, privacy curtain, lockable door Gown and cover sheet Gloves for provider and assistant Surgical lubricant Speculum appropriate for patient: Graves (small, med, large) or Pederson Light source Supplies for Pap and GC/chlamydia tests Procto swabs (also known as fox swabs) Monsels /silver nitrate sticks if recent gynecological procedure Pad / panty liner / tissues for post-procedure Female chaperone is required; assistant may be used in this role Privacy 21

22. VETERANS HEALTH ADMINISTRATION Further Evaluation Nurses are often asked to explain at least the basics of pelvic US and endometrial biopsy procedures… Specific Treatment – Medications NSAIDs (e.g., ibuprofen, naproxen) Hormonal contraceptives (e.g., OCPs, Depo) Pelvic UltrasoundEndometrial Biopsy 22

23. Image used with permission from Krames StayWell Pelvic Ultrasound Transabdominal What is it? Test to look at organs and structures in the pelvis. How is it done? A “transducer” sends out sound waves that bounce off body structures like an echo to create a picture. A gel, spread on the pelvis, allows smooth movement of the transducer over skin and eliminates air between the skin and transducer to improve sound conduction. A typical exam takes 30-60 minutes. Are there risks? No radiation exposure. Usually painless. May have some mild discomfort as the transducer is guided over a full bladder. 23

24. Photo source: Krames Pelvic Ultrasound Transvaginal Image used with permission from Krames StayWell What is it? Test to look at reproductive organs. How is it done? A probe, covered with a condom and surgical lubricant, is inserted in the vagina. It sends out sound waves that bounce off body structures to create a picture. What are you looking for? Abnormal findings, such as fibroids. Thickness of the endometrial stripe. Risks? No radiation exposure. Generally painless, but pressure from the probe could be uncomfortable. Patients with vaginal atrophy/ dryness might be uncomfortable. 24

25. Endometrial Biopsy What is an endometrial biopsy? Tissue is taken from uterine lining (endometrium) and checked for abnormal or malignant cells. How is it done? Office-based, no sedation, typically pre-medicate with an NSAID. Patient will lie down with feet in foot rests. Provider will insert speculum to visualize the cervix. Cervix is cleaned with antiseptic and then grasped with a tenaculum to stabilize the uterus. Cervical dilator may be used to open cervical canal if there is stenosis. Small, hollow, plastic tube is gently passed into uterine cavity. Gentle suction removes sampling of the lining. Patient might be taken to OR for HSC, D&C with anesthesia. However, office procedures are safe – we have seen decreases in morbidity and mortality since office-based endometrial biopsies were introduced. When is it recommended? For abnormal bleeding…heavy or prolonged. Generally women >40. What are you looking for? Cause of abnormal bleeding Checking for endometrial cancer (very accurate for diagnosing endometrial cancer) What are potential complications? Are rare; generally a very safe procedure Infection, bleeding, cramping Perforation of the uterus 25

26. Endometrial Biopsy Image used with permission from Krames StayWell

27. VETERANS HEALTH ADMINISTRATION Back to our 42 yo veteran with “heavy” vaginal bleeding…… Normal endometrial biopsyUltrasound showed 2 small fibroidsBleeding was controlled by low-dose oral contraceptive Whether or not fibroids are causing the heavy bleeding is not certain – it could be just changes in her cycle as she approaches the perimenopausal years. 27

28. VETERANS HEALTH ADMINISTRATION Vaginal bleeding in a woman with a new positive pregnancy test may be due to: A.Threatened abortion B.Incomplete spontaneous abortion C.Ectopic pregnancy D.Vaginal laceration/abrasion E.All of the above Question… 28

29. VETERANS HEALTH ADMINISTRATION Case Study 2 33-year-old Veteran Normal cycles, but over past 4-6 weeks has had spotting on most days and some heavier bleeding for a few days Sexually active with a single male partner What are ALWAYS your two primary triage concerns? 29

30. 1)Is she hemodynamically stable? 2)Is she pregnant? After establishing status of her hemodynamic stability and pregnancy, you can move on to a more detailed pain assessment, assessment of her menstrual patterns, other symptoms, and estimated blood loss. Note that this evaluation follows the same steps as the evaluation for the previous patient. 30

31. VETERANS HEALTH ADMINISTRATION Case Study 2 Continued…. No acute distressNormal vital signsNo painPositive urine pregnancy test 31

32. VETERANS HEALTH ADMINISTRATION What Diagnoses Do You Need to Have in Mind? 1 st trimester (Spotting may be normal, but some abnormalities need to be kept in mind) 2 nd & 3 rd trimester (Bleeding is NEVER normal; causes might include abruptio placenta or placenta previa) Unrelated to pregnancy (Vaginal lesions or lacerations, cervical polyps, or ectropion may still occur –why the exam is important ) 32

33. Ectopic pregnancy outside of uterus (97% of time in fallopian tube) Miscarriage (impending, inevitable, incomplete, or complete AB) Physiologic or implantation bleeding (small amount of spotting/bleeding approx 10-14 days after fertilization; diagnosis of exclusion; no intervention) Non-pregnancy causes (discussed already) Causes of First Trimester Bleeding 33

34. VETERANS HEALTH ADMINISTRATION Vaginal bleeding in a woman with a new positive pregnancy test may be due to: A.Threatened abortion B.Incomplete spontaneous abortion C.Ectopic pregnancy D.Vaginal laceration/abrasion E.All of the above Answer 34

35. Back to the case of our 33 yo Veteran with irregular vaginal bleeding… Next steps for evaluation Pelvic exam Serum pregnancy test (levels of HCG will be checked against weeks of gestation + US) Ultrasound Referral for OB care (if woman does not have an ectopic, chances of adverse outcomes are low, but still must be followed closely by OB) 35

36. VETERANS HEALTH ADMINISTRATION Does recurrent bleeding or spotting between periods require further evaluation? A.Yes B.No Question… 36

37. VETERANS HEALTH ADMINISTRATION 24-year-old Veteran Spotting between her periods which come like clockwork every 28 days. No missed cycles. No pain, cramping, vaginal discharge. No sexual activity for over 6 months What are possible causes? Case Study 3 37

38. Causes of Intermenstrual Bleeding Hormonal Contraception (most common) IUDInfection Cervical Polyps or Ectropion Endometrial polyps Cancer Postcoital Bleeding Physiologic (spotting at time of ovulation due to decline in estrogen) Many of these may be evident on exam, so a complete H&P is the next step.

39. VETERANS HEALTH ADMINISTRATION Answer Does recurrent bleeding or spotting between periods require further evaluation? A.Yes B.No As we have just reviewed, physiologic bleeding is a diagnosis of exclusion. Therefore, a pelvic exam with cervical cancer screening is the MINIMUM evaluation this patient will need. Likely that she will need additional evaluation beyond that. 39

40. VETERANS HEALTH ADMINISTRATION 65-year-old Veteran Light vaginal bleeding, occurring on two days in past 3 weeks Menopause 12 years ago Sexually active with long-term female partner What questions should you ask? Case Study 4 40

41. VETERANS HEALTH ADMINISTRATION Emphasis is a bit different when assessing postmenopausal women… with vaginal bleeding Pregnancy −Less concern about pregnancy as women get older −HOWEVER, if a patient is still menstruating, there is a chance of pregnancy… we have seen pregnancy in women who are in their early 50’s Hemodynamic stability −Difficult to assess hemodynamic stability over the phone −HOWEVER, this patient reported small amounts of bleeding. If indeed there is little bleeding, hemodynamic instability is less of a concern. 41

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43. Postmenopausal Bleeding Possible Causes Atrophy Cancer Polyps/Fibroids/Adenomyosis Medications (HRT, herbal or dietary supplements) Infections Other (diseases in adjacent organs, post-radiation) 43

44. VETERANS HEALTH ADMINISTRATION Primary goal of evaluating postmenopausal bleeding is to exclude malignancy History Physical exam, pelvic exam, Pap Ultrasound and/or endometrial biopsy* Different approach may be used for patients on hormone replacement therapy 44

45. VETERANS HEALTH ADMINISTRATION Key Points for Vaginal Bleeding 45

46. VETERANS HEALTH ADMINISTRATION Authors Laure Veet, MD Women’s Health Services, Office of Patient Care Services, VHA Central Office Deborah Ingram, PhD, ARNP-BC Malcom Randall VAMC, Gainesville, FL Melissa McNeil, MD, MPH VA Pittsburgh Health Care System Linda Baier Manwell, MS Univ of Wisconsin-Madison Division of General Internal Medicine Molly Carnes, MD, MS Univ of Wisconsin-Madison Center for Women’s Health Research 46