45 year old woman with PV Bleeding

Max Brinsmead PhD FRANZCOGMarch 2010

Which of the following tests are required for a 45-year old Para 4 who is suffering from prolonged vaginal bleeding at intervals of 3 to 6 weeks? She has a normal sized uterus to clinical evaluation.

A 45-year old Para 4 with prolonged vaginal bleeding every 3 - 6 weeks? Examination - NAD Ultrasound pelvis Full blood count Pap smear Coagulation profile Liver function tests Serum Iron Serum ferritin Endometrial biopsy CT pelvis and

abdomen Serum CA125

Renal function tests Office hysteroscopy TSH Thyroid function tests Serum FSH & LH Serum beta HCG Serum oestradiol Serum prolactin Serum Progesterone D&C uterus None of the above

A 45-year old Para 4 with prolonged vaginal bleeding every 3 - 6 weeks? Examination - NAD Ultrasound pelvis To evaluate the

endometrium.If diffusely thickened it suggests that a Pipelle biopsy would be useful

Exclude submucous fibroid(s)

Other fibroids of less interest because the uterus is not enlarged

Ovarian imaging useful

A 45-year old Para 4 with prolonged vaginal bleeding every 3 - 6 weeks? Examination - NAD Full blood count Check HB

RBC’s may show signs of chronic blood loss

Platelet count

Excludes major blood dyscrasia

A 45-year old Para 4 with prolonged vaginal bleeding every 3 - 6 weeks? Examination - NAD Pap smear This is not a test for

cervical cancer. If that is suspected after visual inspection and palpation then biopsy is required

Should be done if not previously done or overdue

A 45-year old Para 4 with prolonged vaginal bleeding every 3 - 6 weeks? Examination - NAD Coagulation profile A clotting disorder is very

rarely the cause of this problem

This is not a first line test

Ask about “other bleeding and bruising”

Check family history

Warfarin but not aspirin or NSAID may be relevant

A 45-year old Para 4 with prolonged vaginal bleeding every 3 - 6 weeks? Examination - NAD Liver function tests Renal function tests

This patient requires a blood test and adding these two to a FBC is sensible

Renal failure may present with menstrual disorder

Liver failure can cause a coagulopathy

A 45-year old Para 4 with prolonged vaginal bleeding every 3 - 6 weeks? Examination - NAD Serum Iron Serum ferritin

Not first line tests but may be required if anaemia is a problem

Serum ferritin is favoured by NZ DOH as a criterion for the Mirena for which this patient may be a candidate

A 45-year old Para 4 with prolonged vaginal bleeding every 3 - 6 weeks? Examination - NAD Endometrial biopsy If there is diffuse widening

of the endometrial echo a simple Pipelle sampling will exclude cancer of the endometrium with >97% sensitivity

Some pathologists would prefer that you do this before administering progestins

A 45-year old Para 4 with prolonged vaginal bleeding every 3 - 6 weeks? Examination - NAD CT pelvis and

abdomen

Not unless you (or the patient or the radiologist) are prepared to pay for it!

A 45-year old Para 4 with prolonged vaginal bleeding every 3 - 6 weeks? Examination - NAD Serum CA125 Not required

It would be indicated if the ultrasound disclosed a suspicious ovarian mass

But it is not recommended as a screening test for ovarian cancer

I sometimes use a menstrual phase CA125 for a patient with possible endometriosis

But only when laparoscopy is not readily available

A 45-year old Para 4 with prolonged vaginal bleeding every 3 - 6 weeks? Examination - NAD TSH Thyroid function

tests

Thyroid dysfunction may present as a menstrual problem

Look for other symptoms and signs

TSH is the best screening test

A 45-year old Para 4 with prolonged vaginal bleeding every 3 - 6 weeks? Examination - NAD Serum FSH & LH Serum beta HCG Serum oestradiol Serum prolactin Serum Progesterone

Although anovulation is the most likely diagnosis endocrine studies are rarely used or useful

Do not use a high FSH to label the patient as “postmenopausal”

Ask about hot flushes instead

Always exclude pregnancy

A 45-year old Para 4 with prolonged vaginal bleeding every 3 - 6 weeks? Examination - NAD D&C uterus A 21st century

gynaecologist would favour ultrasound +/- saline ultrasonography or Pipelle sampling or office hysteroscopy

45 yo Para 4 with vaginal bleeding every 3 – 6 weeks. Bleeding now for 11 days. Ultrasound NAD. No symptoms or signs of acute or chronic blood loss. What is the best way of stopping the bleeding?

45-yo P4 with vaginal bleeding for 11 days. Examination & ultrasound- NAD. How best to stop the bleeding? Oral oestrogens IV Oestrogen Oral Progestin IM Depot Provera Oestrogen and

Progestin by mouth Tranexamic acid

(Cyklokapron) Mirena IUS Danazol D&C uterus

45-yo P4 with vaginal bleeding for 11 days. Examination & ultrasound- NAD.

Oestrogens by mouth

This patient may already be hyperoestrogenic

There is a risk of thromboembolism

45-yo P4 with vaginal bleeding for 11 days. Examination & ultrasound- NAD.

IV Oestrogens IV Premarin said to be very effective

There is a risk of thromboembolism

45-yo P4 with vaginal bleeding for 11 days. Examination & ultrasound- NAD.

Oral Progestin Creates a decidual-like

endometrium

Use Norethisterone 5 -10 mg Q6H til bleeding stops then BD for 10 – 12 days

Has progestogenic and oestrogenic actions

There is a theoretical risk of thromboembolism

Warn the patient about withdrawal bleeding

45-yo P4 with vaginal bleeding for 11 days. Examination & ultrasound- NAD.

IM Depot Provera Unpredictable in onset

Unpredictable in duration

45-yo P4 with vaginal bleeding for 11 days. Examination & ultrasound- NAD.

Oestrogen & Progestin by mouth

Using any form of oral contraceptive pill may be effective

However, BD or TDS dose required my be an unacceptable risk of thromboembolism

45-yo P4 with vaginal bleeding for 11 days. Examination & ultrasound- NAD.

Tranexamic acid (Cyclokapron)

Will reduce menstrual flow in 85% of women but it is not the drug of choice to stop bleeding here

There is no risk of thromboembolism when used according to directions i.e. 500 – 1000 mg TDS or QID

45-yo P4 with vaginal bleeding for 11 days. Examination & ultrasound- NAD.

Mirena IUS A very good option

Circulating concentration of d-norgestrel equivalent to 2 tablets of Noriday per week

Troublesome irregular bleeding can occur for 6 – 16 weeks

45-yo P4 with vaginal bleeding for 11 days. Examination & ultrasound- NAD.

Danazol Would probably work

Indicated in the management of menorrhagia

Expensive

Has more androgenic side- effects than progestins

45-yo P4 with vaginal bleeding for 11 days. Examination & ultrasound- NAD.

D&C uterus Both diagnostic and therapeutic

Requires hospitalisation and usually GA

And the patient may have the same problem next cycle!