Abnormal Uterine Bleeding

Martin DeBono & Lisa Pickles

(consultant, O&G) (GP)
NICE guidance: Heavy Menstrual
Bleeding 2007.

Be aware of this – complements our

guidance.
 ABNORMAL UTERINE
BLEEDING

1/ Menorrhagia 2/ Irregular 3/ Postmenopausal

Bleeding Bleeding

2a <40years old 2b >40 years old

 ABNORMAL UTERINE
BLEEDING

1/ Menorrhagia 2/ Irregular 3/ Postmenopausal

Bleeding Bleeding

2a <40years old 2b >40 years old

1/ Menorrhagia- summary of guidelines.

Regular, heavy bleeds with normal examination, no

need for hysteroscopy.

Treatment options: - TXA, MFA, COC

- Mirena
- Depo provera

Refer GYNAECOLOGY OPD if all options fail (to

discuss surgical management)
Surgical Treatments for Menorrhagia.
Other
Normal
Normal uterus
uterus treatments Fibroids
+/- small fibroids failed. >3cm diameter.
+/- small fibroids
<3cm diameter No desire to retain
<3cm diameter. uterus.

Endometrial Hysterectomy Treat the

ablation. (vaginal if poss.) Fibroid

Uterine artery
Myomectomy
embolisation
 ABNORMAL UTERINE
BLEEDING

1/ Menorrhagia 2/ Irregular 3/ Postmenopausal

Bleeding Bleeding

2a <40years old 2b >40 years old

2/ Irregular Bleeding – summary of guidelines.

2a/ <40years 2b/ > 40years

UNLIKELY to need
MAY need
hysteroscopy.
hysteroscopy(expanded
on next slide)
Causes:
Causes:
Contraception?
Infection? Malignancy?
Cervix? Perimenopause?
PCOS? HRT?
 2b/ > 40years old (irregular bleeding)

Work out SIGNIFICANCE of bleeding.

Significant Not significant

IMB No IMB
Continual spotting Period-like flow
No recognisable cycle Recognisable periods,
even if irregular, short or
long cycle.

Hysteroscopy Observe then? hysteroscopy

 ABNORMAL UTERINE
BLEEDING

1/ Menorrhagia 2/ Irregular 3/ Postmenopausal

Bleeding Bleeding

2a <40years old 2b >40 years old

 ABNORMAL UTERINE
BLEEDING

1/ Menorrhagia 2/ Irregular 3/ Postmenopausal

Bleeding Bleeding

2a <40years old 2b >40 years old

 Risk factors for endometrial
carcinoma.
Remember these :
Obesity
PCOS
Diabetes
Hypertension.
Infertility/nulliparous
Tamoxifen
Early menarche/late menopause.
FH ca colon/emdometrium
 ABNORMAL UTERINE
BLEEDING

1/ Menorrhagia 2/ Irregular 3/ Postmenopausal

Bleeding Bleeding

2a <40years old 2b >40 years old

3/ PMB – summary of guidelines

URGENT referral DAPH.

( Direct Access Programmed Hysteroscopy. May

have transvaginal scan for endometrial thickness.
If >4mm then hysteroscopy).
Notes re DAPH for problem bleeding
1 referral urgency

Urgent
< 2 weeks post menopausal bleeding
high suspicion of uterine cancer,
eg suspicious examination, multiple risk factors
for endometrial Ca with significant bleeding.
Soon
Perimenopausal bleeding – significant (see earlier descriptors)

Routine
13 week Normal examination
Perimenopausal, persistent, not significant bleeding

2 contraindications to hysteroscopy
Pregnancy, Recent PID, Cervical pathology (refer to Colposcopy OPD)
Abnormal vaginal bleeding
Case Quiz
When to refer for hysteroscopy
Answer a/ no action or medical management
b/refer hysteroscopy
c/other
(assume normal exam,swabs,smear, preg test etc unless
otherwise stated)

1/.
50 year old. Cycle heavy 5-7/20-35.
Answer a/ no action or medical management
b/refer hysteroscopy
c/other
(assume normal exam,swabs,smear, preg test etc unless
otherwise stated)

2/.
35 year old with menorrhagia (no IMB).
Not responded to medical management
including mirena coil.
Answer a/ no action or medical management
b/refer hysteroscopy
c/other
(assume normal exam,swabs,smear, preg test etc unless
otherwise stated)

3/.
30year old with heavy periods and mid cycle
bleeding
Answer a/ no action or medical management
b/refer hysteroscopy
c/other
(assume normal exam,swabs,smear, preg test etc unless
otherwise stated)

4/.
45 year old.Regular cycle 5/28.
LMP started after 21 day cycle, now spotting
or brownish loss for 5 weeks since then.
Answer a/ no action or medical management
b/refer hysteroscopy
c/other
(assume normal exam,swabs,smear, preg test etc unless
otherwise stated)

5/.
41 year old.
Cycle regular 6/26-30 with spotting
in between for past 6/12.
Answer a/ no action or medical management
b/refer hysteroscopy
c/other
(assume normal exam,swabs,smear, preg test etc unless
otherwise stated)

6/.
49 year old.
Cycle 5-7/28-56 for past year.
LMP-flooding for 2 days, normal loss for
3 days, then stopped
Answer a/ no action or medical management
b/refer hysteroscopy
c/other
(assume normal exam,swabs,smear, preg test etc unless
otherwise stated)

7/.
46 year old.Cycle 5-7/20-35.
LMP started after 28 day cycle,
flooding for 2 days and now spotting,
brown loss , which has continued for 2 weeks.
Answer a/ no action or medical management
b/refer hysteroscopy
c/other
(assume normal exam,swabs,smear, preg test etc unless
otherwise stated)

8/.
55 year old with vaginal dryness.
LMP 5 years ago.
Atrophia on examination.
Reports brown/red streaky loss for 3 months
on and off.
Answer a/ no action or medical management
b/refer hysteroscopy
c/other
(assume normal exam,swabs,smear, preg test etc
unless otherwise stated)

9/.
52 year old.
LMP 14 months ago.
Reports a period for 5 days.
 GREY AREAS
Assume normal exam, swabs, smear, preg test etc unless stated

1/ 37 year old, obese, diabetic, PCOS, with IMB.

 GREY AREAS
Assume normal exam, swabs, smear, preg test etc unless stated

2/ 52 year old. Had period 9/04.

2/06.
Seen 6/06 when above symptoms reported.
 GREY AREAS
Assume normal exam, swabs, smear, preg test etc unless stated

3/ 84 year old with vaginal dryness, LMP 25 years

ago.
OE/ atrophia.
Reports brown/red loss on and off for 3 months.
 GREY AREAS
Assume normal exam, swabs, smear, preg test etc unless stated

4/ 41 year old. Regular menorrhagia.

Hb=9.1 (microcytic).
 Comments

1/ Place of ultrasound?

2/ Norethisterone ? In menorrhagia.
? In irregular bleeding.
 Comments – contd:

3/ Anaemia ? Refer or not.

4/ Adnexal mass & irregular bleeding:

-?urgent hysteroscopy
-? 2 week gynae cancer referral
 Summary/key messages

Regular menorrhagia does not usually need

hysteroscopy.

In over 40s, think about SIGNIFICANCE of irregular

bleeding:
significant – IMB, not recognisable as period (refer)
not significant – No IMB, period-like flow (may not
need referral).

PMB needs urgent DAPH (may have US scan)

?? QUESTIONS??
 References.
• Nice Guidance: Heavy menstrual
bleeding. January 2007.
• Abnormal Vaginal Bleeding – primary
care pathway, Calderdale. Find this on
Pennine website. ( www.pennine-gp-
training.co.uk ). March 2007.