Management Of Abnormal Vaginal Bleeding.ppt.ppt

Management of Abnormal Vaginal Bleeding,Dr Maggie ThomsonMay 2009,Look at the problem in 4 different stages,Post pubertalMiddle reproductive lifePerimenopausalPostmenopausal,Post pubertal,Menarche in the UK is about 12.6 yearsIt is genetically controlledInitiation of the process involves an interaction with the percentages body fat and genetic determination of the age of onsetEarly cycles are in the majority anovulatoryMay take 5-8 years before menstrual cycle normality is establishedThe lack of ovulation and lack of production of progesterone leads to endometrial hyperplasia and thus heavy menstrual loss,“Metropathia haemorrhagica”,Post pubertal bleeding problems,They are for the vast majority of girls,self limitingTherefore,the most important thing in dealing with them is reassuranceTHEY WILL COME RIGHT IN THE END,Suggested treatment plans:,HB 12g/lReassuranceHB 10-12g/lCyclical progestogens(21 days out of 28)OR The Combined Contraceptive Pill Suggest stopping these on an annual basis to see if the normal pattern has establishedHB 10g/lCOC for a continuous period to correct anaemia,and then used cyclically after thatIf none of these work,consider scan to exclude very rare uterine pathology(Beware TVS if not sexually active),MIDDLE REPRODUCTIVE LIFE,What is“abnormal”?PCBIMBMenorrhagiaOligo-amenorrhoea,Remember in this group of patients,exclude pregnancy and thus ectopic as a cause of irregular bleeding(Mole if follows a pregnancy),Postcoital bleeding:causes,Vaginal lesions(rare)TraumaBenign cervical lesionsPolypsCervical erosionCervicitis:,Most importantly:Chlamydia:PCB reported in 18%of womenMalignant cervical lesionsSquamous carcinomaAdenocarcinoma,Intermenstrual bleeding:causes(Remember that IMB and PCB are often indistinguishable),Normal:occurs in 1-2%of cycles periovulatory Exogenous hormones:COC(poor compliance)POPIUSDepoprovera*Implanon*IUD(premenstrual)Endometriosis(Pre and post menstrual),Uterine:Endometrial polyps(common cause)Fibroids:submucous fibroids can present with IMBEndometritis and PID:Can cause but not frequentlyDysfunctional uterine bleeding:most likely to cause irregular cycles with or without menorrhagiaEndometrial and myometrial malignancy;uncommon but important,*Do not refer until I year after DEPO or those on Implanon,Management of PCB and IMB,History:age,frequency,contraceptive history,smears,sexual historyExamination:AbdominalLOOK at the cervix(discharge,contact bleeding,tenderness,polyp)Other possible sites of bleedingFB or IUCD tailInvestigations:Smear if indicatedConsider chlamydia and other swabs,Who should you refer?,Persistent IMB and or PCB without any unusual featuresWomen with a friable erosionWomen with PCB/IMB with an abnormal smearWomen on hormonal therapy:Women on progestogenic methods only if the bleeding is excessively frequent or prolonged(remember chlamydia in these!),From the gynaecologists view point,Malignancy is very rare in this group of women,so investigations from our point of view are to exclude any serious causes,but not necessarily to treat the symptomsExaminationColposcopy only if abnormal smear or abnormal looking cervixCervical biopsy(again only if looks suspicious)Ultrasound scanEndometrial biopsyHysteroscopy if EB not possible or polyps seen,Pipelle Endometrial Biopsy,Menorrhagia,Menorrhagia,Heavy bleeding defined as menstrual blood loss more than 80mlOften subjectiveMay be caused by:IdiopathicFibroidsIUD(not the IUS)Pelvic infection(painful)Bleeding disorders,NICE definition of heavy menstrual bleeding(HMB),“Excessive menstrual blood loss which interferes with the womans physical,emotional,social and material quality of life,and which can occur alone or in combination with other symptoms.”,History taking,examination and investigations,History needs to cover nature and any related symptoms that might suggest structural or histological abnormalityIf it does,(IMB,PCB,Pelvic pain and/or physical symptoms),physical and/or other investigations(US)should be performed.If it does,not pharmaceutical Rx can be started initiallyFBC 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.,Physical examination,Should be carried out before:IUS fittingsInvestigations for structural abnormalitiesInvestigations referred to a specialistFor histological abnormalitiesWomen with fibroids that are palpable abdominally or who have intra-cavitory fibroids and or uterine length as measured at US 12cm should be offered referral to a specialist,Investigations at secondary care,HistoryAbdominal examinationSpeculumBi-manual examinationEndometrial biopsy:Age 45,persistent IMB/PCB,treatment failure or ineffective treatmentUltrasound is first line to identify structural abnormalitiesFibroids:need no.,size and locationHysteroscopy used if failed EB,scan not helpful and want to see exact location of fibroid(D&C not to be used alone),Treatment options:pharmaceutical,First line:The IUSSecond line:Transenamic acid(3 cycles if no help)Anti-prostaglandins(3 cycles if no help)COCThird line:NET,day 5-26 of cycleInjectable progestogensOther:GNRH analogues(longer than 6/12,add back HRT),Treatment options:surgical,Endometrial ablationFirst generation:Rollerball and TCRESecond generation:Novasure(Impedance)Thermal balloonMEA(Microwave),Ablation techniques,Used if severe impact on life and no desire to conceiveCan be used with small fibroids(3cm)Larger ones can be resected if submucosal with TCREPREFERABLE to hysterectomy if the uterus is no bigger than10-week pregnancy,Management of fibroids,Uterine artery embolisation:For fibroids 3cm,severe impact on quality of life and who want to retain uterus and avoid surgeryFertility is potentially retained,but problem of ovarian failure in over 45s,Management of fibroids,MyomectomySevere impact on life,3cmIf submucosal,resect with TCRE,followed by Rollerball(if fertility not an issue)Surgical myomectomyFertility potentially retained,but may be adhesions,recurrence and infection.May also need hysterectomy if bleeds,Hysterectomy for Fibroids,Indicated for fibroids 3cm and severe impact on quality of life.Patients should be aware that the operative risks are greater for hysterectomy for fibroids.Route should be discussed,but may be difficult to do it vaginally with large fibroids.,Hysterectomy for HMB,Not first line solely for HMB.Consider when:Other treatments have failed,are contra-indicated or declinedDesire for amenorrhoeaFULLY informed woman requests itNo desire to retain uterus and fertility,Total,Subtotal,?LAVH,Risks,Removal of ovaries at hysterectomy,NICE 2007“Do not remove healthy ovaries”,Still produce androgens after the menopauseRisk 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-removalEven if you take them out,risk of ovarian CA remains in the peritoneumAlthough may be more difficult to remove afterwards,not a justification to do soAlways problems for some with ERT,Recommended readingwww.nice.org.uk,Copyright 2005 BMJ Publishing Group Ltd.,Reid,P.C et al.BMJ 2005;330:938-939,Number of hysterectomies for menorrhagia from 1989-90 to 2002-3 in NHS trusts in England,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 aboveThe difference is that the risks of malignancy are much higherCervixHyperplasia(atypical)Endometrial CAEndometrial polyps are more commonAND:the length of time for the problem to persist is obviously less!,Management of perimenopausal bleeding problems,Reassurance if no pathology foundHRT if bleeding problems associated with menopausal symptoms(Femoston 2:20)Cyclical progestogens,for 3 weeks out of 4.EG.NET,Provera and DydrogesteroneThe IUS,Advantages of the IUS,Longer term solution if requiredFewer systemic side effects compared to oral Rx(no increased risk of VTE)Can be used in fibroids as long as not submucosalCan be part of HRTAmenorrhoea welcomed at this stage of reproductive life,without the need for surgery,PMB,10%of cases of PMB will be caused by CA endometriumThe use of HRT has increased the uncertainty as to what constitutes unscheduled bleeding requiring referral for investigationTamoxifen use has increased for Breast CA and is associated with a 3-6x fold increase in the risk of Endometrial CA,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”,What is“Abnormal”bleeding in women on HRT?,Sequential regimes:May be heavy or prolonged at the end of or after the progestogen phase,orOccur at any time(BTB),Continuous Combined regimes:*It occurs after the first 6 months of treatment,orIt occurs after amenorrhoea has been established,*Far more likely if started too early,“If referred to the gynaecologist,an examination is not always necessary”,“However,examination by GP or practice nurse can alter the course clinical management if it expedites referral on grounds of raised suspicion of a malignancy”,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”,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.,3mm,3mm,Post-test risk:0.6-0.8%,Post-test risk:20-22%,Estimated pre-test risk of CA:10%,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:0.1-0.2%,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,Hysteroscopy,Indicated where EB not possibleIf scan suggests possible polyp,endometrial polyp,EB insufficient for diagnosisIf on TamoxifenOutpatient or inpatient,Finally,