Transcript Shoulder Difficulty

Max Brinsmead PhD FRANZCOG
July 2010
The common causes are…

Pregnancy-related
○ Successful but threatening to miscarry
○ Unsuccessful & aborting
○ Retained products of conception
- After normal pregnancy or miscarriage
○ Ectopic

Cervical Bleeding
 Benign
 Ectropion, Cervicitis or Polyp
 Cancer of the cervix

Bleeding from the uterine cavity
 Benign
 Fibroids and Polyps
 Cancer
 Dysfunctional uterine bleeding
But also keep in mind…

Hormones that have been given
○ Depoprovera (or DMP or DMPA)
○ Oral contraceptives (COC)
○ Other

Bleeding disorders
○ Rare
○ Usually associated with other bleeding or
bruising
When a patient complains about abnormal
vaginal bleeding...
 First determine if she has:
○ Regular but heavy or prolonged periods
 This is called menorrhagia
 It is a common manifestation of fibroids
 Rarely due to a bleeding disorder
○ Regular periods with bleeding at other times
 If the bleeding is postcoital it should be regarded as
cancer of the cervix until proven otherwise
○ Irregular bleeding
 This may be dysfunctional uterine bleeding but this
diagnosis is usually only made when other causes
are excluded

And always exclude pregnancy
 Best done by pregnancy test
Consider your patient’s age…

If the patient is young (<35 years)
○ Cancer is uncommon

If the patient is very young & never
sexually active
○ Pregnancy, STD and Ca cervix never occurs
○ But dysfunctional uterine bleeding is not
uncommon

If the patient is >40 years
○ Cancer from within the uterine cavity can only
be excluded by endometrial biopsy or curette
○ But dysfunctional bleeding is not uncommon
You must always examine…
Look for signs of anaemia
 Examine the abdomen to see if there is a
uterus or other mass arising out of the
pelvis
 Pass a speculum and decide if the
bleeding is coming from or through the
cervix
 Examine the pelvis bimanually to see if
the uterus is enlarged

○ (And if the cervix feels normal if it looked
abnormal)
Dysfunctional Uterine Bleeding (DUB)

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Often a history of missed periods or
irregular cycles
May be associated with obesity and
hirsutism (PCO Disorder)
Bleeding is usually painless unless there is
clot colic
Bleeding can be very heavy or quite
prolonged
There is a normal cervix and the uterus is
not enlarged
Management of Abnormal Vaginal Bleeding

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Antibiotics have no place nor role
Bleeding from an abnormal cervix is rarely
a life-threatening emergency but it requires
referral for further testing and treatment
Transfusion should be reserved for those
with severe anaemia and in whom you
cannot immediately control the bleeding
Uterine bleeding after the age of 40
requires referral for D&C
Dysfunctional uterine bleeding can be
treated with Pills
Management of Dysfunctional Uterine Bleeding

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Bleeding can be controlled with Norethisterone
(5 mg tablets)
Give 2 tablets every 2 – 3 hours until the
bleeding slows or stops
Then 5 mg BD for 10 – 14 days
The patient can then expect a “normal
period” a few days after stopping the pills
Give COC in the next cycle
or Norethisterone 5 mg BD from day 10 –
25 of each cycle for 4 – 6 months
Give iron & folate to treat anaemia
Emergency treatment of any Endometrial
Bleeding
When the blood is coming through the
cervix
 Even if the patient is >40 years
 Or if the uterus is enlarged by
adenomyosis or fibroids
 Or the patient has a bleeding disorder
 You can try Norethisterone 10 mg every
2 – 3 hours
 But refer also for further Ix and Rx

Management of Hormone-related PV
bleeding
Irregular PV bleeding with Depoprovera or
COC is secondary to their effect on the
endometrium
 But make sure that the cervix is normal
 Then try Norethisterone as per DUB
regimen

 Or give Premarin 1.25 mg 8 hourly
 Or any COC one tablet 6 hourly
 Or just give another injection of Depoprovera