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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!