Abnormal vaginal bleeding Case Quiz When to refer for hysteroscopy

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Abnormal Uterine Bleeding
Martin DeBono Lisa Pickles
(consultant, OG)
(GP)
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NICE guidance Heavy Menstrual Bleeding 2007.

• Be aware of this complements our guidance.

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ABNORMAL UTERINE BLEEDING
1/ Menorrhagia
Irregular Bleeding
2/
3/
Postmenopausal Bleeding
2a lt40years old
2b gt40 years old
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ABNORMAL UTERINE BLEEDING
1/ Menorrhagia
Irregular Bleeding
2/
3/
Postmenopausal Bleeding
2a lt40years old
2b gt40 years old
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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)
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Surgical Treatments for Menorrhagia.
Normal uterus /- small fibroids lt3cm diameter
Other treatments failed. No desire to retain
uterus.
Fibroids gt3cm diameter.
Normal uterus /- small fibroids lt3cm diameter.
Hysterectomy (vaginal if poss.)
Endometrial ablation.
Treat the Fibroid
Myomectomy
Uterine artery embolisation
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ABNORMAL UTERINE BLEEDING
1/ Menorrhagia
Irregular Bleeding
2/
3/
Postmenopausal Bleeding
2a lt40years old
2b gt40 years old
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2/ Irregular Bleeding summary of guidelines.
2a/ lt40years UNLIKELY to need hysteroscopy. Cause
s Contraception? Infection?
Cervix? PCOS?
2b/ gt 40years MAY need hysteroscopy(expanded on
next slide) Causes Malignancy? Perimenopause? H
RT?
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2b/ gt 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
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ABNORMAL UTERINE BLEEDING
1/ Menorrhagia
Irregular Bleeding
2/
3/
Postmenopausal Bleeding
2a lt40years old
2b gt40 years old
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ABNORMAL UTERINE BLEEDING
1/ Menorrhagia
Irregular Bleeding
2/
3/
Postmenopausal Bleeding
2a lt40years old
2b gt40 years old
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Risk factors for endometrial carcinoma.

• Remember these
• Obesity
• PCOS
• Diabetes
• Hypertension.
• Infertility/nulliparous
• Tamoxifen
• Early menarche/late menopause.
• FH ca colon/emdometrium

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ABNORMAL UTERINE BLEEDING
1/ Menorrhagia
Irregular Bleeding
2/
3/
Postmenopausal Bleeding
2a lt40years old
2b gt40 years old
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3/ PMB summary of guidelines
URGENT referral DAPH. ( Direct Access Programmed
Hysteroscopy. May have transvaginal scan for
endometrial thickness. If gt4mm then hysteroscopy).
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Notes re DAPH for problem bleeding

• 1 referral urgency
• Urgent
• lt 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)

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Abnormal vaginal bleedingCase QuizWhen to refer
for hysteroscopy
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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.
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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.
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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
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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.
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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.
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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
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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.
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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.
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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.
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GREY AREAS
Assume normal exam, swabs, smear, preg test etc
unless stated
1/ 37 year old, obese, diabetic, PCOS, with IMB.
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GREY AREAS
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.
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GREY AREAS
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.
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GREY AREAS
Assume normal exam, swabs, smear, preg test etc
unless stated
4/ 41 year old. Regular menorrhagia. Hb9.1
(microcytic).
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Comments
1/ Place of ultrasound?
2/ Norethisterone ? In menorrhagia.
? In irregular bleeding.
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Comments contd
3/ Anaemia ? Refer or not.
4/ Adnexal mass irregular bleeding
-?urgent hysteroscopy -? 2 week gynae cancer
referral
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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)
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?? QUESTIONS??
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References.

• Nice Guidance Heavy menstrual bleeding. January
  2007.
• Abnormal Vaginal Bleeding primary care pathway,
  Calderdale. Find this on Pennine website. (
  www.pennine-gp-training.co.uk ). March 2007.