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?