Transcript Menstrual Disorder

Abnormal uterine
Bleeding
Dr Stanford Wong / Dr Tereza Indrielle
Learning Objectives
• definitions
• assessment
• Diagnosis
• FIGO PALM-COEIN classification
• treatment
Definition (2009)*
• “Any variation from the normal menstrual
cycle, and includes changes in regularity and
frequency of menses, in duration of flow, or
in amount of blood loss.”
*Reference: I.S. Fraser, H.O.D. Critchley, M. Broder, M. G. Munro, 2011, “The FIGO Recommendations on
Terminologies and Definition for Normal and Abnormal uterine Bleeding” Seminars in Reproductive Medicine
Sep;29(5), Page 383-390
Normal variance
• Regularity: 18-24 days
• Frequency: 24-38 days
• Duration: 3-8 days
Subdivision
Categories based on:
• Volume of menstruation
(Normal, Heavy, Light)
• Regularity (Regular, Irregular, Absent)
• Frequency (Normal, Frequent, Infrequent)
• Duration (Normal, Prolonged, Shortened)
• Chronicity (Acute, Chronic)
• Timing related to reproductive status
(Inter-menstrual, Pre-menstrual, Break-through)
Abbreviations
• HMB (Heavy Menstrual Bleeding)
• Excessive menstrual blood loss which interferes with
the woman’s life
• HPMB (Heavy, Prolonged Menstrual Bleeding)
• As above + exceeding 8 days in duration
• AUB (Abnormal Uterine Bleeding)
• Acute AUB: require immediate intervention to
prevent further blood loss
• Chronic AUB: presentation for most of the last 6
months
Abbreviations
• IMB (Inter-menstrual Bleeding)
• PCB Post-coital bleeding (post-intercourse)
• PMB (Post-menopausal Bleeding)
• Bleeding occuring more than 1 year after the last
period
Frequency
• Amenorrhoea
• No bleeding in a 90 days period
• Primary / secondary
• Oligomenorrhea >38 days
• Polymenorrhea <24 days
Clinical Assessment
• Clinical history:
• PC and HPC:
• Associating symptoms
(Eg. Vaginal discharge, Pelvic pain or pressure)
• Sexual and reproductive history
• Symptoms suggestive of anaemia
• Symptoms suggestive of systemic causes of bleeding
• Impact on social and sexual functioning, and quality of
life
• PMH, PSH
Drug History
• Especially medications that can associate
with AUB:
•
•
•
•
•
•
•
Anticoagulants
Hormone Contraceptives
Tamoxifen
Antidepressants
Anti-psychotics
Corticosteroids
Herbal (Eg. Ginseng, Danshen , Chasteberry)
Family History
• Inherited coagulation disorders
• Poly-cystic Ovarian Syndrome
• Endometrial cancer
• Colonic cancer (especially HNPCC)
• Woman with HNPCC have lifetime risk:
• 40-60% for Endometrial cancer, Colorectal cancer
• 12% for ovarian cancer
Risk factors for endometrial cancer*
• Age
• Obesity (BMI > 30kg/m2)
• Nulliparity
• Personal history of
• PCOS
• Diabetes Mellitus
• Hereditary Non-Polyposis Colorectal Cancer
*Reference: Timothy Rowe (Editor in Chief), May 2013, “ Abnormal Uterine Bleeding in Pre-Menopausal
Women”, Journal of Obstetrics and Gynaecology Canada, Volume 35, Number 5
Investigate vs. Treat quickly?
• NICE:
• If cancer not suspected start
treatment before investigations (apart
form Mirena)
Gynaecological examination
• Inspection
• Bimanual examination
• Rectal examination
• If suspected for PR bleed
• Bedside tests:
• Cervical smear
• High vaginal swabs, Endocervical swabs
Investigation
• Pregnancy test or Serum βHCG
• Blood tests:
• Full Blood Counts
• Others: clotting profile, thyroid function test etc.
• Imaging – TV scan
• Pathology/Histology – pipelle and
hysteroscopy!
FIGO Classification
(PALM-COEIN)
• Structural causes:
• Polyps
• Adenomyosis
• Leiomyomas
(Submucosal, Others)
• Malignancy and
Hyperplasia
• Non-structural:
•
•
•
•
•
Coagulopathy
Ovulatory dysfunction
Endometrial
Iatrogenic
Not yet specified
Structural Investigations
• Trans-vaginal Ultrasound (First line)
• If appropriate:
•
•
•
•
•
Hysteroscopy
Saline infusion sonography
MRI
Dilation and Curettage
Endometrial biopsy
Red Flags
• Suspicious features of gynaecological cancer:
• Post-coital bleeding, PMB
• Persistent IMB
• >45 years old with treatment failure
• While on HRT or Tamoxifen
• Pelvic Mass
• Enlarged Uterus (>10 weeks on clinical assessment or >10cm uterine
cavity length on USS)
• Moderate/Severe anaemia on usually benign pathology
• Failure of medical treatment (patient’s own assessment)
• >3 months of drug treatment
• >6 months on IUS
First Line Treatments
(NICE Recommendation)
• Tranexamic acid / Mefenamic acid
• Combined oral contraceptives
• Norethisterone
• Levonorgestrel-releasing intra-uterine system
(LNG-IUS)
Treatment
Potential Unwanted Outcomes
Common
5% Risk of expulsion over 5 years (most likely
with the first menses after insertion)
Irregular Bleeding (usually <6 months)
Hormone related (minor and transient)
- Eg. Breast tenderness, acne, headache
Uncommon
Amenorrhoea
Rare
Uterine perforation at time of insertion
Uncommon
Indigestion, Diarrhoea, Headaches
Common
Indigestion, Diarrhoea
Rare
Asthma exacerbation, Peptic ulcer disease
Common
Mood changes, Headache, Nausea, fluid
retention, Breast tenderness
Very Rare
DVT, Stroke, Ischaemic heart disease
LNG-IUS
Tranexamic
Acid
NSAIDs
Combined
oral
contraceptive
Treatment
Potential Unwanted Outcomes
Oral
Progesterone
Common
Weight gain, Irregular bleeding,
Amenorrhoea, PMS
Rare
Depression
Common
Weight gain, Ireegular bleeding,
Amenorrhoea, PMS
Uncommon
Reduced bone mineral density
(Largely recovered when treatment
discontinued)
Common
Menopausal-like symptoms
Uncommon
Osteoporosis (Particular >6 months use)
Injected
Progesterone
GnRH
Analogue
Surgical - ablation
Dilation and curettage
• No longer recommended as a therapeutic treatment
Potentially fertility sparing…
• Uterine artery embolisation
• Should be first line for patient presented with large fibroid
(>3cm), present with HMB and other significant symptoms
• Myomectomy
Oophorectomy or Not?
• Patient wants it
• FHx of gynae cancer
• Adds extra risks to the procedure
• NOT recommended for healthy ovaries!
Treatment
Endometrial
ablation
Uterine artery
embolisation
Myometectomy
Potential Unwanted Outcomes
Common
Vaginal discharge, Worsen dysmenorrhoea,
Need for additional surgery
Uncommon
Infection
Rare
Perforation (very rare with second
generation technique)
Common
Persistent vaginal discharge, Postembolisation syndrome
Uncommon
Need for additional surgery, Premature
ovarian failure, Haematoma
Rare
Haemorrhage, Tissue necrosis, Speticaemia
Uncommon
Adhesion, Need for additional surgery,
Recurrence, Perforation, Infection
Rare
Haemorrhage
Treatment
Potential Unwanted Outcomes
Common
Infection
Uncommon
Intra-operative haemorrhage, Damage to
abdominal organs, Urinary dysfunction
Rare
Thrombosis
Very Rare
Death
Common
Menopausal-like symptoms
Hysterectomy
Oophorectomy
at time of
hysterectomy
*Reference: BMJ Learning “Heavy menstrual bleeding in secondary care - in association with
NICE”
- http://learning.bmj.com/learning/module-intro/heavy-menstrual-bleeding-secondarycare.html?locale=en_GB&moduleId=6055070
MOCK EXAM!
40 year old with HMB. When you take a further history, she tells you
that she also has some bleeding after sex.
examination of her vagina and cervix:
•What is the diagnosis?
1. Normal examination
2. Bacterial Vaginosis
3. Vaginal cancer
4. Cervical Polyp
Cervical polyp
• Other causes of PCB
• Endometrial polyps
• Vaginal cancer
• Cervical cancer
• Trauma
• 26 year old
• Menorrhagia + dysmenorrhea
• no regular medication
• no children
• no plans to have any until after her
husband finishes his qualifications in 18
months' time.
Levonorgestrel releasing
intrauterine system
First line treatment, >12 months provision of symptomatic relief and contraception
• 30 year old
• tried Mirena, tranexamic acid, and COCP
• unable to tolerate NSAIDs
Endometrial ablation
Next step after failure of medical treatment, Minimally invasive procedure
• A 40 year
• heavy periods
• 5 cm fibroid
• wants to avoid surgery
Uterine artery embolisation
Suitable for fibroid >3cm, Benefits of treatment without surgery
• 35 year old
• Menorrhagia
• Doesn’t plan more children
• No good with tablets
Levonorgestrel releasing
intrauterine system
First line treatment, suitable for both symptomatic relief and contraception,
No need for oral tablets
Reference
• http://www.ladycarehealth.com/how-to-treat-dysfunctional-uterine-bleeding/
• I.S. Fraser, H.O.D. Critchley, M. Broder, M. G. Munro, 2011, “The FIGO
Recommendations on Terminologies and Definition for Normal and Abnormal uterine
Bleeding” Seminars in Reproductive Medicine Sep;29(5), Page 383-390
• NICE clinical guideline 44, “Heavy menstrual Bleeding” January 2007
• Timothy Rowe (Editor in Chief), May 2013, “ Abnormal Uterine Bleeding in PreMenopausal Women”, Journal of Obstetrics and Gynaecology Canada, Volume 35,
Number 5
• http://www.hopkinsmedicine.org/healthlibrary/test_procedures/gynecology/dilation
_and_curettage_d_and_c_92,p07772/
• “Management of Acute Abnormal Uterine Bleeding in Nonpregnant ReproductiveAged Women”, American College of Obstetricians and Gynaecologists Committee
Opinion No. 557, Obstet Gynaecol 2013: 121:891-6
• BMJ Learning “Heavy menstrual bleeding in secondary care - in association with NICE”
- http://learning.bmj.com/learning/module-intro/heavy-menstrual-bleedingsecondary-care.html?locale=en_GB&moduleId=6055070
Any questions?
THANK YOU!