Abnormal vaginal bleeding Case Quiz When to refer for hysteroscopy

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Abnormal Menstrual Bleeding - GP perspective.
Lisa Pickles
(GP, Brig Royd, Ripponden)
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Plan for the talk.

• Present local guidelines (2007 Martin De Bono and
  Lisa Pickles).
• Compare with NICE guidelines.
• Referring to menorrhagia
• irregular bleeding
• postmenopausal bleeding
• (PCB and amenorrhoea looked at separately)

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Local Guidance/pathway.

• Abnormal Uterine Bleeding.
• on www.pennine-gp-training.co.uk (go
• to Clinical, then womens health)
• Or, is on CHT website (CK healthcare
• Trust) under pathways, gynae.

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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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Compare with NICE guidelines for Heavy Menstrual
Bleeding

• See handout.

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The differences Local v. NICE

• NICE -1st IUS
• -2nd TXA, MFA or COC (choice?).
• -3rd Depo Provera or norethisterone.
• Local - 1st and 2nd choices as above all
• offered initially.
• - then Depo Provera (not
• norethisterone).

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The differences, continued

• NICE examine if structural or histological
  abnormality possible.
• (? Scan. Fibroids lt3cm can be treated medically).
• Local examine all patients.

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The differences, continued.

• NICE consider endometrial biopsy if IMB or, in
  women gt 45, treatment failure.
• Local intermenstrual bleeding is dealt with
  separately by Irregular Bleeding guidelines.
• (IMB intermenstrual bleeding).

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Remember FBC.
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PCT evidence based guidelines for hysterectomy
referral.

• Concept of referring patient to consider a
  procedure as opposed to advice regarding a
  clinical condition.
• Primary care to ensure other therapies have been
  tried as detailed.
• ? Patient choice and preference?
• Available on the PCT Link . Seems to fit with
  NICE guidelines.

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PCT evidence based guidelines, contd

• Before referring for hysterectomy, patient to
  have tried IUS
• - TXA, MFA, COC, depo (if
• indicated).
• And, to have undergone an endometrial ablation
  procedure (which has failed).

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PCT evidence based guidelines, contd

• Refer using referral form.

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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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Case History.

• A 45 year old patient comes to see you with
  regular heavy menstrual bleeding. Normal
  examination and FBC. What do you offer?

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IUS/ oral TXA, MFA, COC or2nd line, Depo
Provera.
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She is reluctant to consider an
intrauterine method and has a past history of
focal migraine (gt 5 years ago is UKMEC 3 FSRH).
Questioning reveals longstanding
dysmenorrhoea.What might be your choice?
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Mefenamic acid.
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A look at her PMH reveals asthma and she
admits that she became wheezy after OTC ibuprofen
a few years ago, which she has avoided since.
What do you offer now?
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Tranexamic acid.
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Disappointingly, she tries TXA for 3 months,
but it does not help. Now what do you do?
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Show her an IUS and offer explanation
regarding insertion technique.
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Whilst this often helps to reassure
patients, your patient still declines an IUS.
What factors should you consider before advising
Depo Provera?
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Check for osteoporosis risk factors (in view
of bone mineral density concerns), due to her
perimenopausal age.
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She is thin, a smoker (20/day despite
advice), does no weight bearing exercise and has
taken several courses of steroids over the years
for her asthma.You decide not to start
depo.What next?
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Refer to gynae clinic to consider an
endometrial ablative procedure.
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2 years later, her HMB recurs. What do you do
now?
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Refer for hysterectomy using referral form.
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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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Explanatory notes see full guidelines.
Reference at end.

• 2d/. Options for medical treatment for heavy
  bleeding.
• - COC (if no CI/non smoker)
• - cyclical progesterones
• (eg. medroxyprogesterone acetate 10mg tds,
  dydrogesterone 10mg bd. Note most commonly used
  rx is progesterone, but article in FSRH journal
  last year suggested that is has partly
  oestrogenic properties after being broken down in
  fat tissue, consider as similar risk to 20mcg COC
  at therapeutic doses. Contraception doses seem
  unaffected)
• - Mirena esp if menorrhagia also. D/w patient
  pre DAPH referral. Issue leaflet.
• - ?? HRT. Controversial.

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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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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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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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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)
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/ progesterones ? 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.

• Abnormal Uterine Bleeding, local
  pathway/guidelines 2007. www.pennine-vts-co.uk
• NICE guideline 44 Heavy Menstrual Bleeding
  January 2007. www.nice.org.uk
• Calderdale PCT the Link via GP email. Evidence
  based referral for hysterectomy.
• Faculty of Sexual and Reproductive Healthcare
  (for UKMEC, contraception gt 40 years etc).
  www.ffprhc.org.uk

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