how to approach case of abnormal vaginal bleeding

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How to approach a case of abnormal Vaginal
bleeding
DRMANAL BEHERY Assistant Professor, Zagazig
University 2013
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Definition

• Any uterine bleeding that is excessive in amount
  ,duration or frequancy

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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.

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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.

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• 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

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classification

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

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Systemic Etiologies

• Coagulation defects
• Leukemia
• ITP
• Thyroid dysfunction
• Liver disease

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Reproductive Tract Causes

• Gestational events
• Malignancies
• Benign
• Atrophy
• Leiomyoma
• Polyps
• Cervical lesions
• Foreign body
• Infections

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Most Common Causes of Reproductive Tract AUB

• Pre-menarchal
• Foreign body
• Reproductive age
• Gestational event
• Post-menopausal
• Atrophy

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Iatrogenic Causes of AUB

• Intra-uterine device
• Oral and injectable steroids
• Psychotropic drugs

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Dysfunctional causes

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

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Doctor, Im bleeding funny

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

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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

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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

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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

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Endometrial aspiration
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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

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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

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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

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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\

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When to consider medical treatment as failure?

• Failure to relieve patients symptoms after 3
  months
• Remains anemic after 3 months

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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

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Other modalities of treatment

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

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Abnormal Uterine Bleeding in Women of
Childbearing Age
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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.

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Most likely diagnosis?

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

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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?

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Investigations

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

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What if anovulatlon persists for more than 4
years-

• chance of spontaneous correction is low
• Likely to be frank PCOS

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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

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Case cont,

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

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What is the next step

• Organic pathology to be ruled out (Fibroids and
  adenomyosis (
• Rule out Pregnancy complications
• Rule out endometriosis and pelvic Infection

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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

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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

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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

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What is the most likely diagnosis

• Ovulatory DUB or
• Idiopathic menorrhogia

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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)

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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.

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Sonohysterography

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

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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

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Sampling How?

• Endometrial aspiration
• Conventional DC
• Hysteroscopy and directed biopsy

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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.

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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

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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

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• 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

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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?

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Mrs. JP Differential Diagnosis

• Endometrial Pathology
• Carcinoma
• Benign eg Polyp
• Cervical Pathology
• Other genital tract pathology
• Ovarian Ca
• Trauma
• Dysfunctional Uterine Bleeding
• Blood dyscrasia

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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

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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

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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?

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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

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DO YOU SEND THIS PATIENT FOR SCAN?

• Yes
• Both transabdominal and transvaginal scan is
  required

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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.

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DO YOU SEND THIS PATIENT FOR BLOOD TESTS?

• Yes
• WHAT TESTS WOULD YOU ORDER?
• HB
• S. Ferritin
• Pap smear
• TSH

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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

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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

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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

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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.

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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

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

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• 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

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• 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

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• 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.

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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

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• 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).

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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

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THANK YOU