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how to approach case of abnormal vaginal bleeding

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Undergraduate course lectures in gynecology ,prepared by DR Manal Behery,Faculty of medicine,Zagazig University – PowerPoint PPT presentation

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Title: how to approach case of abnormal vaginal bleeding


1
How to approach a case of abnormal Vaginal
bleeding
DRMANAL BEHERY Assistant Professor, Zagazig
University 2013
2
Definition
  • Any uterine bleeding that is excessive in amount
    ,duration or frequancy

3
Normal menses
  • Every 28 days /- 7 days
  • Mean duration is 4 days.
  • More than 7 days is abnormal.
  • Average blood loss with menstruation is 35-50cc.
  • 95 of women lose lt60cc.

4
Forms
  • Metrorrhagia
  • Uterine bleeding occurring at irregular but
    frequent intervals.
  • Menometrorrhagia
  • Prolonged uterine bleeding occurring at irregular
    intervals.
  • Menorrhagia
  • Prolonged bleeding
  • gt 7 days or gt 80 cc
  • occurring at regular intervals.

5
  • Oligomenorrhea
  • Reduction in frequency of menses Between 35 days
    and 6 months.
  • Hypomenorrhea
  • Reduction on number of days
  • Reduction in amount of flow
  • Polymenorrhea
  • Increases frequancy of menses lt21 day
  • Menotaxises
  • Increase number of days
  • Normal amount of the flow

6
classification
  • Organic
  • Systemic
  • Reproductive tract disease
  • Iatrogenic
  • Dysfunctional
  • Ovulatory
  • Anovulatory

7
Systemic Etiologies
  • Coagulation defects
  • Leukemia
  • ITP
  • Thyroid dysfunction
  • Liver disease

8
Reproductive Tract Causes
  • Gestational events
  • Malignancies
  • Benign
  • Atrophy
  • Leiomyoma
  • Polyps
  • Cervical lesions
  • Foreign body
  • Infections

9
Most Common Causes of Reproductive Tract AUB
  • Pre-menarchal
  • Foreign body
  • Reproductive age
  • Gestational event
  • Post-menopausal
  • Atrophy

10
Iatrogenic Causes of AUB
  • Intra-uterine device
  • Oral and injectable steroids
  • Psychotropic drugs

11
Dysfunctional causes
  • Dysfunctional uterine bleeding is the most commom
  • After puberty
  • Before menopause
  • After labor or abortion

12
Doctor, Im bleeding funny
  • What is your first question?
  • How do you help her define bleeding funny?
  • How do you quantify her bleeding?

13
A practical approach (step 1)
  • History
  • Age(before puberty, reproductive age ,PM)
  • Pattern of bleeding cyclic or a cyclic
  • Marital state complication of pregnancy
  • Drug intake ,hormonal ttt, HRT
  • previous treatment
  • last cervical smear

14
A practical approach (step2) Physical examination
  • General obesity? thyroid? pallor? pulse?
    Cachexia?
  • Abdomen palpable mass?
  • Pelvis cervical or vaginal lesion?
  • Bimanual examuterine size
  • Speculum cervical lesion
  • PR rectum or parametrium

15
A practical approach(step 3) investigation
  • Assessment of the endometrium (not needed for
    women with very low risk of Ca endometrium)
  • endometrial aspirate
  • ultrasound pelvis (transvaginal) to assess
    endometrial thickness
  • Sonohystrography
  • Hysteroscopy
  • CT ,MRI for endometrial invasion

16
Endometrial aspiration
17
REFER (for endometrial aspiration and TVS if
  1. Over 40 years
  2. high risk of endometrial carcinoma
  3. genital tract lesion suspected (except cervical
    polyp)
  4. bulky uterus
  5. previous medical treatment fail

18
If none of the above factors Consider those
investigations
  • cervical smear if sexually active and last smear
    more than 1 year ago
  • CBC if menorrhagia
  • ultrasound pelvis if PV not possible
  • Thyroid function, coagulation profile only when
    history suggestive

19
A practical approach (step4) medical ttt
  • For women under 40 with no suspicion of organic
    lesions either
  • Hormonal (for irregular bleeding as well as
    menorrhagia)
  • combined OC
  • progestogen only (21 days needed)
  • Non-hormonal (for menorrhagia)
  • NSAID
  • antifibrinolytic agent

20
Choice of medical treatment for menorrhagia
  • NSAID 30 decrease in blood loss ,relieve
    dysmenorrhoea as well
  • Antifibrinolytic (transamine) 50 decrease
  • Combined OC effective but need to take through
    out the month, effective contraception as well
  • Progestogen only less effective, need 21 days,
    not effective contraception
  • Haematinics if anaemic
  • combinations can be used\

21
When to consider medical treatment as failure?
  • Failure to relieve patients symptoms after 3
    months
  • Remains anemic after 3 months

22
Step 5 When to refer?
  • Over the age of 40
  • High risk of endometrial Cancer (obesity, DM,
    PCOD)
  • Uterus gt 10 week size or irregular
  • Cervical pathology suspected
  • No response to medical treatment

23
Other modalities of treatment
  • Levonorgesterol releasing IUCD (Mirena)
  • Endometrial ablation
  • Hysteroscopic removal of polyps or submucous
    fibroids
  • Conventional treatment is hysterectomy

24
Abnormal Uterine Bleeding in Women of
Childbearing Age
25
Case1
  • A 15 year old girl with irregular heavy periods
    presents at your clinic.
  • menarche at the age of 13 and since then is
    having unpredictable irregular periods with
    prolonged bleeding every 2-3 months.
  • She is slightly overweight for her height.

26
Most likely diagnosis?
  • Anovulatory Dysfunctional uterine bleeding the
    commonest cause in 95
  • Initial cycles are anovulatory
  • Regular ovulation takes 1-2 years

27
Differntional Diagnosis
  • Dysfunctional bleeding
  • Bleeding disorders -ITP,VWD etc Endocrine causes
  • Medications
  • Local pathology -TB, FB, malignancies
  • No further significant features are found on
    history or clinical examination.
  • What is the next step?

28
Investigations
  • Haematological
  • Full blood count and peripheral smear Platelet
    count
  • Coagulation screen If indicated
  • Endocrine
  • TFT, PRL
  • Ultrasound

29
What if anovulatlon persists for more than 4
years-
  • chance of spontaneous correction is low
  • Likely to be frank PCOS

30
Case2
  • A 34 year old lady complaining of increasingly
    heavy periods since the last one year attends
    your clinic.
  • She has two children 10 and 8 years and underwent
    laparoscopic sterilization 4 years back.
  • She finds that the bleeding is so heavy that it
    interferes with her daily ' routine

31
Case cont,
  • History of regular heavy periods
  • Speculum and bimanual examination normal
  • Recent cervical smear normal
  • Hb level 9 gm/ 100 nil

32
What is the next step
  • Organic pathology to be ruled out (Fibroids and
    adenomyosis (
  • Rule out Pregnancy complications
  • Rule out endometriosis and pelvic Infection

33
IS coagulation profile and endocrine panel a
routine?
  • Testing for endocrine problems and bleeding
    disorders not routinely recommended
  • unless there are specific pointers in the history

34
Is routine DC or endometrial sampling needed?
  • Not Indicated this age as first line management
    If a woman has regular cycles
  • Probability of an abnormal endometrial histology
    in a woman under 40 with DUB and regular cycles
    is lt1

35
Indication for first line endometrial sampling
  • Irregular periods with obesity and other features
    of PCOS as they are candidates at high risk for
    endometrial cancer at a young age
  • Risk of cancer increases to 14

36
What is the most likely diagnosis
  • Ovulatory DUB or
  • Idiopathic menorrhogia

37
What next?
  • Confirm diagnosis or Idiopathic menorrhagia
  • Check for cycle irregularity, Intermenstrual or,
    postcoltal bleeding
  • Woman With failed first Iine medical management
    are more Iikely in have intrauterine pathology
    and so TVS arid If needed hysteroscopy and
    endometrial sampling are Indicated (RCOS
    guidelines)

38
TVS
  • polyps
  • submucous fibroids
  • Endometrial hyperplasia An endometrial Thickness
    of 12 mm is used as the cut off paint for
    endometrial hyperplasia on TVS (RCOG)
  • Optimal time !s the proliferative phase.

39
Sonohysterography
  • TVS may miss small polyps
  • Difficult to distinguish from thickened
    endometrium
  • SHG helps in
  • accurate diagnosis

40
Endometrial sampling
  • All women with persistent menorrhogia
  • To diagnose or exclude
  • endometrial carcinoma or
  • Hyperplasia
  • Probability of abnormal histology lt 1 in this
    age with regular cycles

41
Sampling How?
  • Endometrial aspiration
  • Conventional DC
  • Hysteroscopy and directed biopsy

42
Case3
  • A 47 year old woman gives a 2 year history of
    irregular periods.
  • She has always had regular cycles until 3 years
    ago.
  • She has three children all delivered normally.

43
Case cont,
  • No significant finding in the histor
  • On examination she is a little overweight
  • Not anaemic
  • Pelvic examination reveals a normal sized
    anteverted mobile uterus
  • Cervical smear is normal

44
What is the likely diagnosis?
  • Anovulatary dysfunctional bleeding
  • Common at the extremes of reproductive life
  • But malignancy is to be ruled out
  • Endometrial sampling a must to detect endometrial
    carcinoma and hyperplasia

45
  • The approach to DUB differs in the different age
    groups and in particular depends on whether the
    bleeding is cyclical or not.
  • The current RCOG recommendations in premenopausal
    women with regular cycles is to delay endometrial
    sampling till medical management has failed.
  • Also the numbers of hysterectomies being done for
    normal sized uteri are coming down with
    Increasing acceptance of Mirena and endometrial
    ablation

46
Case 4
  • Mrs. JP Age 56 Para 1,Complains of a period
    that has been going on for 2 weeks with pain
  • WHAT ARE THE POSSIBLE CAUSES?

47
Mrs. JP Differential Diagnosis
  • Endometrial Pathology
  • Carcinoma
  • Benign eg Polyp
  • Cervical Pathology
  • Other genital tract pathology
  • Ovarian Ca
  • Trauma
  • Dysfunctional Uterine Bleeding
  • Blood dyscrasia

48
what additional information do you require?
  • Usual menstrual pattern
  • Recent menstrual cycles and LNMP
  • Estimate of blood loss
  • Description of the pain
  • Use of hormones - COC or HRT
  • Pap Gynae History
  • Risk factors for endometrial Ca
  • Sexual, contraception social history

49
Mrs. JP Additional History
  • Usual cycle
  • Recent cycles LNMP
  • Estimate of blood loss
  • Description of the pain
  • Use of hormones - COC or HRT
  • Pap Gynae History
  • Risk factors for endometrial Ca
  • Sexual history etc.
  • Monthly until 6m ago
  • Some early and some late. Skipped one month. This
    period 3w late
  • Has used 3 packets pads, some 3 clots.
    Flooding
  • Like labour
  • Nil
  • Regular Paps NAD. One CS and postpartum
    curette. Took pill for 10 yrs then separated
  • Infertility. Hypertension. Obese
  • Celibate since separation

50
What Physical Exam Required for this patient?
  • Signs of anaemia
  • Signs of endocrinopathy
  • Thyroid
  • Androgen excess
  • Examine the cervix
  • ?Pap or ThinPrep
  • Look for cervical mucous
  • Is the cervix open?
  • Uterine size and regularity
  • Pelvic tenderness or adnexal mass?

51
Result of Physical Exam
  • Signs of anaemia
  • Signs of endocrinopathy
  • Thyroid
  • Androgen excess
  • Examine the cervix
  • ?Pap or ThinPrep
  • Look for cervical mucous
  • Is the cervix open?
  • Uterine size and regularity
  • Pelvic tenderness or adnexal mass?
  • Pale. PR 96/min
  • Male type hair distribution
  • Intact but patulous with abundant clear mucous
  • NAD
  • NAD

52
DO YOU SEND THIS PATIENT FOR SCAN?
  • Yes
  • Both transabdominal and transvaginal scan is
    required

53
Mrs. JP Scan Report
  • . Abdominal and transvaginal scans were
    performed.
  • The uterus is enlarged by multiple fibroids the
    largest of which measures 2.5 cm in diameter.
    However, there is no distortion of the
    endometrial cavity which measures 17 mm.
  • . The right ovary is mildly enlarged with a
    volume of 40 cc and the left ovary contains a
    cyst measuring 2.8 x 2.7 cm.
  • This was evaluated with colour Doppler and no
    abnormal vascularity noted.

54
DO YOU SEND THIS PATIENT FOR BLOOD TESTS?
  • Yes
  • WHAT TESTS WOULD YOU ORDER?
  • HB
  • S. Ferritin
  • Pap smear
  • TSH

55
Mrs. JP Pathology Results
  • HB 90 Microcytic and hypochromic film
  • S. Ferritin 5
  • Pap smear ThinPrep NAD but only scanty
    squamous cells are present
  • TSH - normal

56
what would you prescribe for this patient?
  • Rx Tabs Primolut 5 mg TDS for 10 days
  • Ferro-tonic one daily
  • Maybe Nurofen 1-2 Q4-6H

57
Does this patient require?
  • Abdominal CT scan?
  • Immediate DC?
  • Hysteroscopy?
  • Saline sonography?
  • Endometrial biopsy?
  • Hysterectomy?
  • No
  • There are better options
  • This is one that can be performed as an
    outpatient
  • Maybe but best for delineating polyps
  • Pipelle endometrial sampling is the best option
  • Only required if cancer of the endometrium is
    diagnosed

58
Case 5
  • A 66-year-old nulliparous woman who underwent
    menopause at 55 years complains of a 2-week
    history of vaginal bleeding.
  • Prior to menopause she had irregular menses. She
    denies the use of estrogen replacement therapy.
  • Her medical history is significant for diabetes
    mellitus controlled with an oral hypoglycemic
    agent.

59
On examination
  • 90kg weight , height 5 ft,
  • blood pressure 150/90 mm Hg, and temperature is
    99F (37.2C).
  • The heart and lung examinations are normal.
  • The abdomen is obese, and no masses are palpated.
  • The external genitalia appear normal, and the
  • normal sized uterue without adnexal masses

60
  • ? What is the next step?
  • Perform an endometrial biopsy.
  • ? What is your concern?
  • ? Concern Endometrial cancer

61
  • A 60-year-old woman presents to her physicians
    office with postmenopausal
  • bleeding. She undergoes endometrial sampling, and
    is diagnosed with endometrial cancer.
  • Which of the following is a risk factor for
    endometrial cancer?
  • A. Multiparity
  • B. Herpes simplex infection
  • C. Diabetes mellitus
  • D. Oral contraceptive use
  • E. Smoking

62
  • A 48-year-old healthy postmenopausal woman has a
    Pap smear performed,which reveals atypical
    glandular cells. She does not have a history of
    abnormal Pap smears.
  • Which of the following is the best next step?
  • A. Repeat Pap smear in 3 months
  • B. Colposcopy, endocervical curettage,
    endometrial sampling
  • C. Hormone replacement therapy
  • D. Vaginal sampling

63
  • A 57-year-old postmenopausal woman with
    hypertension, diabetes,and a history of PCO
    complains of vaginal bleeding for 2 weeks.
  • The endometrial sampling shows a few fragments of
    atrophic endometrium.
  • Estrogen replacement therapy is begun.
  • The patient continues to have several episodes of
    vaginal bleeding 3 months later.

64
Which of the following is the best next step?
  • A. Continued observation and reassurance
  • B. Unopposed estrogen replacement therapy
  • C. Hysteroscopic examination
  • D. Endometrial ablation
  • E. Serum CA-125 testing

65
  • A 52-year-old woman, who has hypertension and
    diabetes, is diagnosed with endometrial cancer.
  • Her diseases are well controlled. Her
  • physician has diagnosed the condition as
    tentatively stage I disease (confined to the
    uterus).

66
Which of t e following is the most important
therapeutic measure in the treatment of this
patient?
  • A. Radiation therapy
  • B. Chemotherapy
  • C. Immunostimulation therapy
  • D. Progestin therapy
  • E. Surgical therapy

67
THANK YOU
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