Download Abnormal Vaginal Bleeding PPT Lecture Slides

Abnormal Vaginal Bleeding
Objectives
Describe normal menses
Describe various causes of vaginal bleeding
Educate patients about abnormal vaginal bleeding
Triage and perform assessment of patients presenting
with vaginal bleeding
VETERANS HEALTH ADMINISTRATION
Poll Question
What is the average blood loss
during a typical menstrual cycle?
A.
B.
C.
D.
VETERANS HEALTH ADMINISTRATION
20 cc
40 cc
60 cc
80 cc
Case Study 1
42-year-old Veteran
“Heavy” vaginal bleeding
for 3 days
Some cramping
Married, 2 children
VETERANS HEALTH ADMINISTRATION
What
should
be
Case Study
the first
#1
question(s)
on your mind?
Initial Assessment
Hemodynamic
stability
Pregnancy
Abdominal/pelvic
pain
Menstruation
patterns
Other symptoms
Blood loss
Check for hypotension, tachycardia,
orthostasis, fever, ill appearance.
LMP, contraception, menopause,
hysterectomy
• Early pregnancy bleeding may be lifethreatening
• Many women unaware of pregnancy
• Always consider her to be pregnant
and rule that out first
─ Urine test detects pregnancy 2 wks
after conception
─ Serum test detects about 1 wk
after conception
─ All clinics caring for women should
have point-of-care (on-site) urine
pregnancy tests; urine results
faster, newer tests highly accurate
Remaining assessment points discussed later.
Hemodynamically Stable?
NO  urgent evaluation
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Pregnant?
POSITIVE
PREGNANCY TEST  Urgent evaluation
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Poll Answer
What is the average blood loss during
a typical menstrual cycle?
A. 20 cc
B. 40 cc
C. 60 cc
D. 80 cc
Now we’ll explore normal menses,
including average blood loss.
VETERANS HEALTH ADMINISTRATION
Cycle every
24 - 35
days
Symptoms
associated
with
menstrual
cycle
Pad count
not reliable
to quantify
blood loss
Normal
Menses
Duration
2 - 7 days
Average
blood loss
40 ml (2
tbs) per
cycle
Menstrual Cycle
First part of cycle:
• Estrogen dominant 
endometrium builds
Ovulation occurs 14
days before onset of
the next period
After ovulation,
corpus luteum is
formed and creates
progesterone.
Second part of cycle:
• Progesterone
dominant 
endometrium is
stabilized
Correlation Between Cycle Duration
and Bleeding
Intervals
between
cycles
Endometrial
proliferation
Duration of
bleeding
• Shorter intervals between cycles  endometrium has less time
to proliferate  shorter duration of bleeding
• Longer intervals between cycles  endometrium proliferates 
longer periods of bleeding
VETERANS HEALTH ADMINISTRATION
Back to the case of our 42 yo veteran with onset
“heavy” vaginal bleeding and cramping Why does
heavy bleeding occur?
NON-PREGNANT CAUSES: present as…
• Regular, cyclic (ovulatory bleeding)
• Irregular, not cyclic (anovulatory bleeding)
PREGNANCY COMPLICATIONS (discussed later)
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What Causes Ovulatory Bleeding?
Can be heavy, prolonged bleeding at regular intervals
or intermenstrual bleeding
Possible causes:
• Coagulopathy
• Neoplasm/malignancy
• Structural lesions (fibroids, polyps)
• Other (inflammation, infection like STI or endometritis)
VETERANS HEALTH ADMINISTRATION
• Structural lesions can cause
regular, heavy bleeding
• Fibroids or other lesions that
are in or near the lining, in
particular, can cause heavy
bleeding
• Fibroids usually cause regular,
heavy bleeding but can also
cause intermenstrual bleeding
• Other lesions, such as polyps,
or even inflammation and
infection can also cause heavy
bleeding
• Endometritis (infection in the
uterine lining, is particularly
prevalent during post-partum
or post-procedure periods
VETERANS HEALTH ADMINISTRATION
Uterine Lesions
What Causes Anovulation and
Anovulatory Bleeding?
Primary hypothalamic-pituitary dysfunction
• Pituitary tumors and pituitary syndromes
• Stress, eating disorders, intense exercise
Other endocrine problems
• Polycystic ovary syndrome
• Hyper- or hypothyroidism
Medications
• Hormonal contraceptives
Many other causes
• In normal menstrual
cycle, endometrial
lining builds up with
estrogen and
stabilizes with
progesterone
• If ovulation doesn’t
occur, progesterone
isn’t produced
• Thus, endometrium
continues to build,
isn’t stabilized, and
begins to slough off
• A woman might
experience irregular
bleeding which can
be heavy or light
Anovulation
Back to the case…
42-year-old veteran
Hemodynamic
Stability
Pregnancy
What more should you ask?
VETERANS HEALTH ADMINISTRATION
Initial Assessment
Hemodynamic
stability
Pregnancy
Abdominal/pelvic
pain
Menstruation
patterns
Other symptoms
Blood loss
Ask about abdominal or pelvic pain:
• Related to menstrual cramps that
have worsened with increased
flow?
• Something serious like an ectopic
pregnancy (with a positive
pregnancy test)?
• Query pain duration, constant or
cyclical, location (midline or
lateral), sudden onset or gradual
Ask about menstruation patterns
• What is normal for her?
• History of irregular/heavy
menses?
Ask about other symptoms:
• Related to anemia: shortness of
breath, light-headedness,
syncope, fatigue
• Related to infection: fever, chills
Estimating Blood Loss
Try to obtain objective evidence
• For triage, try to quantify bleeding by number of pads the woman
is using, or ask her to compare it with her normal menses.
− Typical definition of profuse bleeding: soaks large sanitary pad or
tampon every hour or two, for two or more hours
− Prolonged uterine bleeding = bleeding for >7 days
• For diagnosis, pad/tampon counts are unreliable. Studies show
50% of women complaining of heavy bleeding have normal blood
loss.
Estimates of blood loss taken by history are not reliable, though you
may get a sense of changes in pattern. CBC and ferritin can help figure
out if she has ongoing, significant blood loss, but these may be normal
in a patient with acute blood loss only.
VETERANS HEALTH ADMINISTRATION
Our 42 yo veteran with onset “heavy”
vaginal bleeding…
Sexually active with husband
No contraception
Regular periods, 3 months of heavy bleeding
Normal vital signs, appears well but worried
Negative pregnancy test; CBC, ferritin, TSH ordered
It was decided that she should be seen by the provider
VETERANS HEALTH ADMINISTRATION
Exam Room Set-Up
Specifics about room set-up and assisting during the exam is covered
in another session, but in general, necessary equipment includes:
•
•
•
•
•
•
•
•
•
•
•
•
Table with foot rests, privacy curtain, lockable door
Gown and cover sheet
Gloves for provider and assistant
Surgical lubricant
Speculum appropriate for patient: Graves (small, med, large) or Pederson
Light source
Supplies for Pap and GC/chlamydia tests
Procto swabs (also known as fox swabs)
Monsels /silver nitrate sticks if recent gynecological procedure
Pad / panty liner / tissues for post-procedure
Female chaperone is required; assistant may be used in this role
Privacy
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Further Evaluation
Specific Treatment – Medications
• NSAIDS (e.g., ibuprofen, narpoxen)
• Hormonal contraceptives (e.g., OCPs, Depo)
Pelvic Ultrasound
Endometrial Biopsy
Nurses are often asked to explain at least the basics of pelvic
US and endometrial biopsy procedures…
VETERANS HEALTH ADMINISTRATION
What is it?
Test to look at organs and
structures in the pelvis.
Pelvic Ultrasound
How is it done?
An instrument called a
“transducer” sends out sound
waves that bounce off body
structures like an echo to create
a picture. A clear gel, placed
between the transducer and
pelvis, allows smooth movement
of the transducer over skin and
eliminates air between the skin
and transducer to improve
sound conduction. A typical US
exam takes 30-60 minutes.
Risks?
No radiation exposure. Usually
painless, but may cause some
mild discomfort as the transducer
is guided over a full bladder.
Transabdominal
Image used with permission from Krames StayWell
What is it?
Test to look at reproductive
organs.
Pelvic Ultrasound
Transvaginal
How is it done?
Probe is inserted into vagina. It
is covered with a condom and
surgical lubricant. Probe sends
out sound waves that bounce off
body structures to create a
picture.
What are you looking for?
Abnormal findings, such as
fibroids. Thickness of the
endometrial stripe.
Risks?
No radiation exposure. Generally
painless, but pressure from
probe could be uncomfortable.
Patients with vaginal atrophy/
dryness might be uncomfortable.
Image used with permission from Krames StayWell
Endometrial Biopsy
What is an endometrial biopsy?
Tissue is taken from uterine lining (endometrium) and
checked in pathology for abnormal or malignant cells.
When is it recommended?
For abnormal bleeding…heavy or
prolonged…generally women >40
How is it done?
Office-based, no sedation, typically pre-medicate with
an NSAID
What are you looking for?
• Cause of abnormal bleeding
• Checking for endometrial cancer
(very accurate for diagnosing
endometrial cancer)
Patient will be lying down with feet in foot rests.
Provider will insert speculum to visualize the cervix.
Cervix is cleaned with antiseptic and then grasped
with a tenaculum to stabilize the uterus. Cervical
dilator may be used to open cervical canal if there is
stenosis. Small, hollow, plastic tube is gently passed
into uterine cavity. Gentle suction removes sampling
of the lining.
Patient might be taken to OR for HSC, D&C with
anesthesia. However, office procedures are safe, and
a decrease in morbidity and mortality from D&C has
been noted since office-based endometrial biopsies
were introduced.
What are potential complications?
• Are rare; generally a very safe
procedure
• Infection, bleeding, cramping
• Perforation of the uterus
Endometrial Biopsy
Image used with permission from Krames StayWell
Back to our 42 yo veteran with
“heavy” vaginal bleeding……
Normal endometrial biopsy
Ultrasound showed 2 small fibroids
Bleeding was controlled by low-dose oral contraceptive
Whether or not fibroids are causing the heavy bleeding is not
certain – it could be just changes in her cycle as she
approaches the perimenopausal years.
VETERANS HEALTH ADMINISTRATION
Poll Question
Vaginal bleeding in a woman with a new positive
pregnancy test may be due to:
A.
B.
C.
D.
E.
Threatened abortion
Incomplete spontaneous abortion
Ectopic pregnancy
Vaginal laceration/abrasion
All of the above
VETERANS HEALTH ADMINISTRATION
Case Study 2
33-year-old Veteran
Normal cycles, but over past 4-6 weeks
has had spotting on most days and
some heavier bleeding for a few days
Sexually active with a single male
partner
VETERANS HEALTH ADMINISTRATION
What are
ALWAYS your
two primary
triage
concerns?
Initial Assessment
Hemodynamic
stability
Pregnancy
Abdominal/pelvic
pain
Menstruation
patterns
1) Is she hemodynamically
stable?
2) Is she pregnant?
After establishing status of
her hemodynamic stability
and pregnancy, you can
move on to a more detailed
pain assessment, assessment
of her menstrual patterns,
other symptoms, and
estimated blood loss.
Other symptoms
Blood loss
Note that this evaluation
follows the same steps as the
evaluation for the previous
patient.
Case Study 2 Continued….
No acute distress
Normal vital signs
No pain
Positive urine pregnancy test
VETERANS HEALTH ADMINISTRATION
What Diagnoses Do You Need to Have
in Mind?
1st trimester
2nd & 3rd trimester
(Spotting may be
normal, but some
abnormalities
need to be kept in
mind)
(Bleeding is NEVER
normal; causes might
include abruptio
placenta or placenta
previa)
VETERANS HEALTH ADMINISTRATION
Unrelated to
pregnancy
(Vaginal lesions or
lacerations,
cervical polyps, or
ectropion may
still occur –why
the exam is
important)
Causes of First Trimester Bleeding
Ectopic pregnancy outside of uterus (97% of time in
fallopian tube)
Miscarriage (impending, inevitable, incomplete, or
complete AB)
Physiologic or implantation bleeding (small amount
of spotting/bleeding approx 10-14 days after
fertilization; diagnosis of exclusion; no intervention)
Non-pregnancy causes (discussed already)
Poll Answer
Vaginal bleeding in a woman with a new positive
pregnancy test may be due to:
A.
B.
C.
D.
E.
Threatened abortion
Incomplete spontaneous abortion
Ectopic pregnancy
Vaginal laceration/abrasion
All of the above
VETERANS HEALTH ADMINISTRATION
Back to the case of our 33 yo Veteran with
irregular vaginal bleeding… Next steps for
evaluation
Pelvic exam
Serum pregnancy test (levels of HCG will be
checked against weeks of gestation + US)
Ultrasound
Referral for OB care (if woman does not have
an ectopic, chances of adverse outcomes are
low, but still must be followed closely by OB)
Poll Question
Does recurrent bleeding or spotting
between periods require further evaluation?
A. Yes
B. No
VETERANS HEALTH ADMINISTRATION
Case Study 3
24-year-old Veteran
Spotting between her periods which
come like clockwork every 28 days.
No missed cycles. No pain, cramping,
vaginal discharge.
No sexual activity for over 6 months
VETERANS HEALTH ADMINISTRATION
What are
possible
causes?
Causes of Intermenstrual Bleeding
Hormonal
Contraception
IUD
Infection
Endometrial
polyps
Cancer
(most common)
Cervical Polyps or
Ectropion
Postcoital
Bleeding
Physiologic
(spotting at time of
ovulation due to
decline in estrogen)
Many of these may
be evident on exam,
so a complete H&P is
the next step.
Poll Answer
Does recurrent bleeding or spotting
between periods require further evaluation?
A. Yes
B. No
As we have just reviewed, physiologic bleeding is a diagnosis
of exclusion. Therefore, a pelvic exam with cervical cancer
screening is the MINIMUM evaluation this patient will need.
Likely that she will need additional evaluation beyond that.
VETERANS HEALTH ADMINISTRATION
Case Study 4
65-year-old Veteran
Light vaginal bleeding, occurring on
two days in past 3 weeks
Menopause 12 years ago
Sexually active with long-term
female partner
VETERANS HEALTH ADMINISTRATION
What
questions
should you
ask?
Emphasis is a bit different when
assessing postmenopausal women…
vaginal bleeding
•with
Pregnancy
− Less concern about pregnancy as women get older
− HOWEVER, if patient is still menstruating, there is a chance
she could be pregnant… we have seen pregnancy in
women who are in their early 50’s
• Hemodynamic stability
− Difficult to assess hemodynamic stability over the phone
− HOWEVER, this patient reported small amounts of
bleeding. If indeed there is little bleeding, hemodynamic
instability is less of a concern.
VETERANS HEALTH ADMINISTRATION
Assessment: POSTMENOPAUSAL
WOMEN
Trauma
(Any precipitating factors? Atrophy?)
Bleeding pattern
(When did it start? Temporal pattern, duration,
postcoital, quantity?)
Associated symptoms
(Pain, fever, changes in bladder/bowel function?)
Medications/supplements
(Hormones, anticoagulants, soy-containing herbal
or dietary supplements?)
Family history
(Breast, colon, endometrial cancer?)
Postmenopausal Bleeding
Possible Causes
Atrophy
Cancer
Polyps/Fibroids/Adenomyosis
Medications
(HRT, herbal or dietary supplements)
Infections
Other
(diseases in adjacent organs, post-radiation)
Primary goal of evaluating postmenopausal
bleeding is to exclude malignancy
History
Ultrasound and/or
endometrial
biopsy*
VETERANS HEALTH ADMINISTRATION
Physical exam,
pelvic exam, Pap
Different approach
may be used for
patients on hormone
replacement therapy
Key Points for Vaginal Bleeding
Multiple causes of abnormal bleeding;
evaluation depends on bleeding pattern, patient
age, other factors
Two main issues for women of childbearing age:
• Hemodynamic stability • Pregnancy
Main issue for postmenopausal women is to rule
out malignancy
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