PV Bleeding: a case presentation
Download
Report
Transcript PV Bleeding: a case presentation
PV Bleeding:
a case presentation
John Alabi
GPST3
23/10/12
History
26 yr old afro-caribbean lady; M.W
‘Golden minute’ – “Dr. I’m getting married
this weekend and will be going away to dubai
for my honeymoon. I feel my period might
coming during this time and I was hoping to
delay it.”
“I would like some medication to stop the
period till I get back!”
History
Heavier periods over last 6 cycles
Progressively worsening
Tired; but not thought much about it “with
planning a wedding and all!!”
Negatives
Fever, N+V
SOB/CP
Palpitations
Abdominal distension
Vaginal discharge
Dyspareunia
Bowel habit
History
Intentionally lost weight for wedding 5kg
Some frequency but no dysuria
Occassional low backpain
Periods are getting more painful than before.
PMHx – nil
Drug Hx. – nil
NKDA
Non-smoker
Alcohol – occassional
Family Hx – Father (Hypertension), Sister
(Hysterectomy)
Obstetric Hx: Nulliparous
Sexually active; single partner for 5 yrs
No previous STI
On COCP (microgynon 30)
Gynae Hx
Menarche = 13 yr
LMP = 3wks ago
K = 5 days (now slightly extending day 6)
Cycle = 28 – 30 days
Initial examination
JACCOL – negative
Cadiovascularly stable
Management
Time up for sessions
Agreed to come back in following honeymoon
for examination
Bloods requested – FBC, E+U, LFT, TFT,
Coag screen
Urinalysis
Advised to omit pill free period and take
COCP ‘back to back
Discussed afterwards with trainer.
Results
Urinalysis – negative
Bloods; Hb – 10.2g/dl otherwise normal
Notes; no hx of cervical smear
Exam
Abdo – full. Soft. Non-tender
Supra-pubic fullness. About 12 -14 week size
uterus
Bimanual exam - 14week enlarged, firm and
irregular uterus. Adnexae are normal
Cervical smear – cervix appeared normal.
taken with permission
Management
Pelvic ultrasound shows an enlarged uterus
with irregular contour and multiple intramural
masses consistent with uterine fibroids. Both
ovaries are visualized and normal
She has been referred to a gynaecologists and
we await further info.
NICE 2007
HMB; excessive menstrual blood loss
interfering with quality of life, or objectively
as loss of > 80ml per menstrual period
Initial assesment – Hx, FBC, and if structural
or histological abnormailty suspected.
USScan if uterus is palpable
Consider biopsy to exclude Ca if; (1) persistent
IMB (2) age > 45yrs (3) failed or ineffective tx
NICE 2007
Mirena IUS – 1st line
Tranexamic acid or NSAIDs – stop after
3cycles if no improvement
COCP
Progestrogen – norethisterone 5mg (day 5-26
of cycle) or as Depo-provera
GnRH analogue
If 1st line fail; consider a 2nd drug option,
consider pelvic exam +/- if not already done
NICE 2007
Endometrial ablation – if no desire to conceive and
fibroids are <3cm
Hysterectomy – no desire to retain uterus or fertility
but wants amenorrhoea
Uterine artery embolization – if fibroids >3cm.
Consider as 1st line if significant symptoms like pain
or pressure. Potentially retains fertility
Myomectomy - >3cm. Potentially retains fertility
review of Systematic medical and surgical tx of HMB: clinical evidence
2012:01:805
NSAIDs and Tranexamic acid (used individually). Good evidence that both are
efftive, resulting in significantly less mean bloodloss than placebo
Tranexamic acide vs. NSAIDs: poor quality evidence but 2 RCT favour tranexamic
acid
Poor quality evidence favouring one NSAID over another
Danazol – was found to be effective & leads to less bloodloss than NSAIDs and
oral progestrogens
Few trials comparing COC, oral luteal phase progestogens, IUS and GNRH
analogues
COC – similar efficacy to NSAIDs
Mirena – 1 RCT; more effective in reducing bloodloss than luteal phase
progestogen at 6mths, and more than COC at 1yr
PO progestrogens- less effective than tranexamic acid and danazol but may be as
effective as NSAIDs
Hysterectomy – definetely effective han other medical or surgical tx. 1/3 experience
comlications but fewer womer overall are dissatisfied
Endometrial destruction techniques –hysteroscopic laser ablation, nonhysteroscopic balloon/microwave ablation). also effective. Complications includes
infction, perforation, haemorrhage
Ullipristal acetate – (NEJM 2012) participants took daily x 3mths resulting in
control of bleeding in 90% of women, ¾ eporting rapid amennorhoea. Further
studies needed to see it s effect on the endometrium as the drug causes some
characteristic changes
Conclusion
Tranexamic acid or NSAIDs
Tranexamic acid now available otc as cyklo-F
or femstrual
COC also confers contraceptive benefits
Surgical options: less invasive and effective
methods are available depending on local
availability and individual choice but
hysterectomy is definitive
Any questions?
Thank you