Vaginal Bleeding non pregnant and in pregnancy Tim Chang MBBS(SYD), FRANZCOG Gynaecologist,...

Vaginal Bleedingnon pregnant and in pregnancy

Tim ChangMBBS(SYD), FRANZCOG

Gynaecologist, Endoscopic surgeon and IVF Fertility specialist

Dr. Christiane MayerMD, FRANZCOG

Obstetrician and Gynaecologist,

139 Dumaresq street

Campbelltown

Sponsored by

Steering committee, Accreditation and Sponsorship

This educational program has been developed with the assistance of a steering committee:

• Dr. Timothy Chang MBBS (SYD), FRANZCOG,

• Dr. Christiane Mayer M.D., FRANZCOG (AUS), Specialist O&G, GP (AUT)

• Dr. Carina Law MBBS, FPA Certificate

4 Category 2 points have been applied for in the RACGP QI&CPD program

This program is brought to you by

AUSTR(AL)IA

Abnormal Uterine BleedingAetiology and Diagnosis

Dr. Christiane MayerMD, FRANZCOG

Obstetrician and Gynaecologist,

139 Dumaresq street

Campbelltown

Learning outcomes

Identify early symptoms of Abnormal Uterine Bleeding

Recognise causes of Abnormal Uterine Bleeding

Assess women of various age groups who present with Abnormal Uterine Bleeding.

Discuss treatment options available to patients with Abnormal Uterine Bleeding

Abnormal Vaginal Bleeding

• Uterus AUB• Vagina• Cervix• Vulva• Fallopian tube

Abnormal Uterine Bleeding (AUB)

• Acute• Chronic: 10 – 35 % of women• Intermenstrual bleeding

• Spontaneous• Provoked eg PCB

Abnormal menstrual bleeding

• Abnormal quantity > 80 mls(change pad/tampon every 1-2 hrs, interfers with daily activities/anaemia)

• Abnormal duration > 5-7 days

• Abnormal frequency < 21 or > 35 days

Heavy menstrual bleeding is common

• Incidence 5% women aged 30-49

• ~ 12% of referrals of premenopausal women to specialist gynaecologists are for evaluation and treatment of HMB

• However, because menstrual disorders are often managed conservatively by GPs, the actual prevalence could be as high as 20% of the reproductiveage female population

FIGO classification system (PALM-COEIN) in 2011 for causes of abnormal uterine bleeding

in non-gravid women of reproductive age

AUB classification - structural

PolypAdenomyosis

Leiomyoma

Malignancy

Polyps

• Localized proliferation of glandular + stroma with single feeder blood vessel

• Exact aetiology unknown:• Abnormal proliferation basal cells

• Incomplete shedding endometrium

• Typical symptoms erratic IMB rarely heavy

• 0.5-5% polyps are malignant in AUB

• recurrence after polypectomy:• blind removal 15%

• visual removal 0-5%

Adenomyosis

• Endometrial glands in the myometrium. Depth invasion varies from 2.5mm-8mm beyond endomyometrial junction• Diagnosis:

• Histopathology• Ultrasound• MRI

• Posterior wall > anterior wall

Leiomyoma

• Common found in up to 70% Caucasian women at age 50 and up to 80% in African descendants

• Mechanisms bleeding:• Increasing surface area

• Biochemical release factors leading to bleeding eg VEGF etc.

• AUB depends on:• Site commonly Submucous

• Size

SM submucosal fibroids

0 Pedunculated intracavitary

1 <50% intramural

2 ≥50% intramural

O other 3 Contacts endometrium 100% intramural

4Intramural

5 Subserosal ≥ 50% intramural

6 Subserosal < 50% intramural

7 Subserosal pedunculated

8 Other eg cervical parasitic

Hybrid leiomyomas (impacts endometrium and serosal)

2 numbers separated by hyphen, endometrium first followed by serosal fibroid

Leiomyoma

Malignancy

• Endometrial Hyperplasia, Carcinoma & Sarcomas of uterus

• Important to rule out in peri – and postmenopausal women

• Tissue diagnosis

AUB classification – non structural

CoagulopathyOvulatoryEndometriumIatrogenicNot otherwise classified

Coagulopathy

• Causes:• Congenital

• Acquired

• Iatrogenic

• Prevalence 13%

• Structured history 90% sensitive

• PFA100 screen+ VWD

• Multidisciplinary clinic

Ovulatory dysfunction

• Hypothalamic pituitary dysfunction eg weight changes, peri menarche / menopause, stress etc

• PCOS• Thyroid • Hyperprolactinaemia• Episodes amenorrhoea with HMB

(Endometrial protection!)

Endometrial

• Regular cycles• Diagnosis exclusion• Mechanisms

• impaired vasoconstrictor production eg endothelin and PGF2α• increased production vasodilators eg PGE2 + PGI• enhanced fibrinolysis

Iatrogenic

• Steroid hormones• OCP enhanced with

• Antibiotics• Anticonvulsants• smokers

• Progestins

• IUD• Mirena• Copper

• Increased prolactin drugs eg • Antidepressants• SSRI• Antipsychotic

Not otherwise classified

• Arteriovenous malformation (AVM)• Congenital

• Acquired eg after post partum

• Infection

AUB – Initial Evaluation

1. History

2. Examination

3. Investigations

Questions to ask your patients when assessing HMB

Volume Are you bothered by the amount of bleeding?

Frequency Do you wake up during the night to change sanitary protection or require frequent changes during the day?

Irregular Are you bleeding or experiencing “spotting” between your regular cycles?

Sexual activity Do you experience bleeding after intercourse?

Pain Are your periods painful?

Mood Does your period make you depressed, tired and moody?

Impact Are your periods affecting your social, athletic, or sexual activity or causing you to miss work?

1.History taking for HMB

1. Menstrual history

2. Sexual history

3. Fertility and pregnancy

4. Medical history

5. Medications

6. Family history

7. Associated symptoms

Associated symptoms

• Anaemia: lethargy, shortness of breath, palpitations

• Thyroid dysfunction: changes in weight, cold intolerance, fatigue, constipation

• Androgen excess: acne, hirsutism

• Pituitary adenomas/prolactinomas: galactorrhoea, headache, visual field disturbances

• Bleeding disorders: easy bruising

• Hypothalamic suppression: weight loss, excessive exercise, stress

• Malignancy: bloating, unexplained weight loss

2.Examination• Vital signs

• General examination - focus on etiology of AUB (?obesity/hirsutism/thyroid/galactorrhea/anorexia…)

• Abdominal examination - ?mass

• Pelvic examination - ? uterine bleedingPAP smear/STI

3.Investigating AUBType of test

Laboratory • Essential: full blood count, β-HCG, Fe, TFT

• Suggested: Coags, Prolactin, FSH/LH/E2/luteal P4, Androgens, SHBG,EUC/LFT, Chlamydia

Physical • Swab (for STI's)

• Pap test

Imaging • Essential:Transvaginal ultrasound (TVUS)

• Possible: Saline sonogram,Hysteroscopy or MRI

Management of Abnormal Uterine Bleeding

Tim ChangMBBS(SYD), FRANZCOG

Gynaecologist, Endoscopic surgeon and IVF Fertility specialist

139 Dumaresq street

Campbelltown

Treatment of AUB• Medical

• Estrogens • OCP• Progestins• Antifibrinolytics• NSAIDs• Androgens• GnRHa

• Mirena• Surgical

• Hysteroscopic surgery• Endometrial ablation• Hysterectomy• Others eg myomectomy

Estrogens

Acute bleeding high dose estrogen effect• IV premarin 25mg every 6 hours• PO progynova 4mg qid

BTB• PO progynova 4mg bd for 2-3 weeks

OCP

Acute bleeding• M50 2 tablets bd until bleeding stops

Chronic AUB• Reduces MBL 50%• Limited studies as effective danazol / NSAIDs in reducing MBL• Less effective than mirena with higher treatment failures

OCP and thromboembolism

• OCP increase risk TE highest first 12 months• Suggested 3rd generation / cyperoterone / drosperinone has increased

risk (x2)• Absolute risks remain small• Risk TE pregnancy x3-5 higher than OCP use

OCP and thromboembolism

Incidence thromboembolism

Non OCP use 1 in 10,000

2nd generation OCP 1 in 5000

3rd generation OCP 1 in 3000

Pregnancy 1 in 1000

Composite data personally derived

OCP and thromboembolism

• High risk factors• Personal hx TE or family hx• Obesity• Smoker• Age

• Ideally commence on 2nd generation OCP• If SE counsel use 3rd generation OCP

Progestins

Acute bleeding• Useful if anovulatory and basalis not denuded• Primolut 10mg tds

Chronic AUB• Useful in AUB-O• 50% reduction MBL• 1/3 stop therapy at 6 months mainly SE• Either continous or cyclic 3/4 weeks eg 5-26

NB luteal phase progesterone NOT effective

Mirena

• reduction MBL 80-95% by 12 months• erratic spotting / BTB with up to 55% in the first 6 months, but only 20% BTB at

12 months• 20% amenorrhoeic at 12 months and 50% at 5 years• 65% patients with Mirena declined hysterectomy after insertion vs 15% on

medical therapy• SE in 20% leading to discontinuation in 1st year eg bloating mastalgia, BTB,

ovarian cysts• 5-10% expulsion rate• perforation 1-2/1000

Mirena

Fibroids• Can be used in fibroids, although expect lower success rate.

• Soysal et al in non randomized study of mirena with SM fibroids (type II <5cm or

type 0/I <3cm) had reduction MBL 90% at 12 months with 5% expulsion rate.

Adenomyosis• reduce dysmenorrhea

• uterine volume

• likely reduce HMB

Antifibrinolytics

• Cyklokapron 500mg 2 tab qid from onset• Useful AUB -E• Reduction MBL 50%• SE

• Nausea, vomiting + diarrhoea• Thrombosis (theoretical) small studies show safe in women previous DVT

NSAIDs

• Useful in AUB-E with other medical therapies• Dysmenorrhoea• Reduction MBL 25%• Given onset menses for the period

Surgical treatments

• 15-58% end up with surgical treatment

• Indications:• Failed medical therapy

• SE medical therapy

• No desire fertility (except myomectomy)

• Patient / surgeon choice

Surgical treatments AUB

• Hysteroscopic surgery• Endometrial ablation (non hysteroscopic)• Hysterectomy

• Vaginal• Laparoscopic• Abdominal• Robotic

Hysteroscopic surgery

• Roller ball ablation• Endometrial resection• Polypectomy• Myomectomy

• Electosurgical• Mechanical

NREA

• Less skill required

• Quicker

• Less complications

• Higher equipment failure

• Limited normal cavities

REA vs NREA

• NSD MBL, amenorrhoea rates, patient satisfaction rates• NREA less OT time, • perforation (OR 0.32)• fluid overload (OR 0.17)• cervical laceration ( 0.22)• haematometra (0.31)• NREA had higher equipment failure

Hysterectomy

• Guaranteed amenorrhoea with high satisfaction rates

• Some serious complications

• Vaginal hysterectomy ideal, but if not feasible,

laparoscopic preferable over laparotomy.

Clinical scenarios

• adolescent

• reproductive age woman

• perimenopausal

• postmenopausal

• acute vaginal bleeding

• Intermenstrual bleeding

Adolescent

• Commonly AUB-O• Exclude coagulopathy / STI• Rarely intrauterine pathology• Medical therapy

• OCP• Progestins• Cyklokapron• NSAIDs

• Mirena

Reproductive age

• Commonly AUB E

• US to exclude pathology

• Medical therapy

• Mirena

Perimenopausal AUB

• Often AUB O• Exclude pathology including cancer• Hysteroscopy • Treatment

• Medical• Mirena • Ablation• Hysterectomy

Postmenopausal

Pathology Atrophic endometrium 60%Endometrial cancer 10%Hyperplasia 15%Polyps 10%Others eg sarcoma, trauma etc 5%

Ultrasound

Cut of mm in PMB Incidence cancer≤ 3mm 4/1000≤ 4mm 12/1000≤ 5mm 23/1000

Endometrial cancer average thickness 21mm

Hysteroscopy + sampling

• Endometrial thickness >3-5mm

• Persistent PMB despite thin endometrium

Conclusions

• AUB common condition encountered by the GP

• Woman’s perception important

• FIGO classification

• Treatment based on age groups

• Individualize therapy

Case study 1Anna, aged 17 years

Anna, aged 17 years

• Presents with heavy and irregular menstrual bleeding and fatigue• Sexually active > 2 yrs, but not in

stable relationship• Uses condomes

How would you assess and manage this patient?

Assessment

• History:• Menarche 13yrs• Irregular heavy periods since menarche• Fatigue recently• Nil obvious bleeding disorder• Nil family Hx• Nil meds• Sexually active

Assessment and initial management

Physical tests:• Pap test• Swab for STIs + Chlamydia PCR

Laboratory tests:• Full blood count, Fe studies• β-HCG• Coag.profile, TSH

Ultrasound TV

Initiate acute management while awaiting results:• Tranexamic acid 1g qid • NSAIDs 2 tablets, 3-4 times a day

( both on days 1–2 of menses)

Results come back negative for chlamydia, but iron deficiency anaemia, U/S nad

Management (AUB – O)• Most likely anovulatory HMB• Immature HPO – axis• Only 56% ovulatory within 4 yrs

after menarche

Treatment:• Iron supplementation• Start OCP as sexually active• Explain SE + VTE risk• Awareness STIs• Consider LNG- IUD if SE from OCP

• F/U in 3-6/12

Case study 2Priya, aged 32 years

Priya, aged 32 years

• Presents with HMB that is irregular in timing

• Overweight (BMI 27 kg/m2)

• Hirsutism

• Acne

• Three children

• Family history of type 2 diabetes

What is in your differential diagnosis at this stage?

Patient assessmentLaboratory tests:• Full blood count• β-HCG• Androgen profile through SHBG, FAI and

testosterone

Physical tests:• TVUS• Pap test• Swab for STIs

• Consider Rotterdam Criteria

Assessment findings

• Androgen profile consistent with PCOS and insulin resistance (without diabetes):

• TV US positive for submucous (SM) fibroid

Result Units Range

Testosterone 1.4 nmol/L (0.2-1.8)

SHBG 23* nmol/L (30-110)

FAI 6.1* % (0.3-4.0)

Treatment approach• Lifestyle change (5–10% weight loss +

structured exercise)

• Combined oral contraceptive pill

• Low oestrogen doses e.g. 20 µg may have less impact on insulinresistance

• Cyclic progestins

• E.g. 10 mg medroxyprogesterone acetate 10–14 days every 2–3 /12

• Metformin ?

• Improves ovulation and menstrual cyclicity

• Monitor insulin resistance

• Refer to Ob/Gyn for SM fibroid

? hysteroscopic resection

Case study 3Lilly, aged 45 years

Lilly, aged 45 years

• Mother of two children, aged 6 and 8

• Presents complaining of heavy menstrual bleeding that is interfering with many aspects of her everyday life

How would you assess the patient?

Patient history• Changing protection every hour

• Cycle timing normal

• Previously tried hormonal therapy and was unhappy with efficacy and side effects

• Doesn’t want any more children

• Had tubal ligation at time of C-section for second and final child

Patient assessment

The patient is advised of potential endometrial disorder and treatment

options, and referred to a gynaecologist

Laboratory tests:• Full blood count • β-HCG• FePhysical tests:• TVUS• Pap test• Swab for STIsResults:• All laboratory and physical tests are

unremarkable• TVUS shows normal cavity with no structural

issues

Endometrial biopsy in women with AUB:

• Age > 40

• Failure of medical treatment

• Riskfactors for endometrial cancer(Age,Obesity,Nullip.,Diabetes,PCOS,HNPCC)

• Significant intermenstrual bleeding

• Women with infrequent menses suggestive of anovulatory cycles

Effectiveness of current management approaches in reducing bleeding to normal

levels or lower

Endometrial ablation*

Hormone therapy

Hysterectomy

*Radiofrequency electrosurgery.

• Oral contraceptive pill reduces bleeding in less than half of patients with 77% eventually seeking surgery

• Hormone-releasing IUD associated with 39% efficacy after 5 years for controlling heavy bleeding with 42% of patients undergoing a hysterectomy within 5 years

Lilly is considering endometrial ablation after Hysteroscopy,D&C

• Destroys a thin layer of the lining of the uterus and reduces the menstrual flow in the majority of women

• Menstrual flow completely stops in ~50% of women

• Provides a non-hormonal option in women who have completed their family

When to refer patients to a specialist

• For further assessment to rule out possible causes, and or treat specific pathologies i.e. myomas, polyps, congenital abnormalities and malignancies

• After failure of conservative management

• At patient request following initial discussion of treatment options

• Where the GP has concerns regarding the presentation

Thank YOU!