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Vaginal Bleeding

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Endometrial ablation. Hysteroscopic resection polyp / fibroid. Hysterectomy. Menorrhagia ... Endometrial ablation. Menorrhagia. Fibroid resection. Menorrhagia ... – PowerPoint PPT presentation

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Title: Vaginal Bleeding


1
Vaginal Bleeding
  • Jo Marsden-Williams
  • SpR
  • 2009

2
Vaginal BleedingKey questions
  • What is the pattern of the bleeding?
  • What age is the women?
  • Does she have abnormal Cx smear?
  • Does she require contraception?
  • Does she require fertility?
  • What has she already tried?
  • Are you WORRIED ABOUT CANCER?

3
Menorrhagia
  • Excess blood loss which interferes with the
    womens physical, emotional, social and material
    quality of life

4
Menorrhagia
  • Objectively 9 - 13.5
  • Subjectively 19-24.5

5
MenorrhagiaPattern of bleeding
  • AGE
  • Number of days of bleeding decreases with age
  • Blood loss increases with age
  • Cycle length reduces with age

6
Menorrhagia
Affects approximately 880,00 women in England
Analysis performed by Information Centre for
health and social care derived from IMS Health
Disease Analyzer
7
Menorrhagia Risk Factors
  • Bleeding disorders - vWD is associated
  • No genetic or racial factors
  • Structural risk factors
  • Uterine fibroids
  • Endometrial polyps
  • Endometriosis / adenomyosis
  • Endometrial hyperplasia
  • Endometrial carcinoma

8
MenorrhagiaInvestigations
  • Only first line investigation necessary
  • FBC

9
MenorrhagiaInvestigations
  • FBC
  • Iron concentration decreases with menstrual loss
    of 60-80 mls
  • Serum Ferritin most accurate test for diagnosing
    iron deficiency anaemia
  • Only test Ferritin if longstanding anaemia

10
MenorrhagiaInvestigations
  • Thyroid function tests
  • Only do if other symptoms
  • Hormones
  • No benefit if regular cycles
  • If considering PCOS
  • Clotting disorders
  • Only if menorrhagia since menarche or family /
    personal history of clotting disorders

11
MenorrhagiaInvestigations
  • USS
  • Examinations is abnormal
  • Uterus is palpable abdominally
  • Vaginal examination reveals a pelvic mass
  • gt 45 years new menorrhagia
  • Persistent IMB
  • Endometrial biopsy
  • Persistent IMB
  • If USS endometrial thickness gt 5mm
  • Hysteroscopy
  • If inconclusive USS / part as treatment

12
MenorrhagiaUterine Pathology
  • lt 40 years
  • 6 endometrial polyps
  • 19 uterine fibroids
  • 0 endometrial ca / hyperplasia
  • gt 40 years
  • 11.5 endometrial / uterine polyps
  • 36 fibroids
  • 1 endometrial cancer
  • 1 endometrial hyperplasia

13
MenorrhagiaMedical treatment
  • Non-Hormonal
  • Lifestyle changes
  • Tranexamic acid
  • Mefenamic acid

14
MenorrhagiaMedical treatment
  • Hormonal
  • IUS (Mirena)
  • COCP
  • Depo-Provera
  • Implanor
  • Norethisterone
  • Danazol

15
MenorrhagiaMirena
  • 38 amenorrhea
  • 72 Oligomenorrhea
  • 21 removed before 5 years
  • 5 years
  • Do not not need USS prior to insertion
  • First line therapy

16
Fibroid Embolisation
17
Fibroid Embolisation
18
Fibroid Embolisation
19
MenorrhagiaSurgical treatment
  • OPTION
  • Endometrial ablation
  • Hysteroscopic resection polyp / fibroid
  • Hysterectomy

20
Menorrhagiaendometrial ablation
21
MenorrhagiaEndometrial ablation
22
MenorrhagiaFibroid resection
23
MenorrhagiaUSS or refer
  • When to do an USS
  • Failed medical therapy
  • IUS
  • Tranexamic acid
  • Mefenamic acid
  • Suspect uterine abnormalities after examination
  • When to refer
  • If you suspect cancer -
  • PMB
  • Colposcopy
  • gynaeoncology
  • Failed medical therapy
  • Suspect significant uterine abnormalities eg
    large fibroid uterus with pressure symptoms

24
MenorrhagiaOrder of therapy
  • First line
  • Mirena
  • Second line
  • Tranexamic acid
  • Mefenamic acid
  • Third line
  • Norethisterone

25
MenorrhagiaPostmenopausal bleeding
  • Refer to PMB Clinic if
  • Postmenopausal bleeding (more than 2 years)
  • gt 45 years new onset menorrhagia
  • gt 45 IMB
  • gt 45 menorrhagia with risk factors
  • Obesity
  • History PCOS

26
MenorrhagiaSecondary to suspected PCOS
  • Due to anovulatory cycles
  • Treatment aimed
  • Health promotion
  • Weight loss
  • Low GI diet
  • Metformin (not licensed for this use)
  • COCP/ Danazol
  • Diagnosis can be made without an USS from
    symptoms and signs. They so not all need to be
    referred
  • www.verity-pcos.co.uk

27
Menorrhagia
  • Questions?
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