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/ Postmenopausa

Bleeding Bleeding

2a <40years 2b >40 years

old old
 ABNORMAL
UTERINE BLEEDING

1/ Menorrhagia 2/ Irregular 3/ Postmenopausa

Bleeding Bleeding

2a <40years 2b >40 years

old 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 Fibroids
Normal
Normal uterus
uterus treatments >3cm
+/- small fibroids failed.
+/- small fibroids
<3cm diameter
diameter.
No desire to
<3cm diameter. retain uterus.

Hysterectomy
Endometrial (vaginal if Treat the
ablation. poss.) Fibroid

Uterine
Myomectom artery
y embolisatio
n
 ABNORMAL
UTERINE BLEEDING

1/ Menorrhagia 2/ Irregular 3/ Postmenopausa

Bleeding Bleeding

2a <40years 2b >40 years

old old
 2/ Irregular Bleeding summary of
guidelines.

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

UNLIKELY to need
MAY need
hysteroscopy.
hysteroscopy(expan
ded 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 Recognisable periods,
cycle even if irregular, short
or long cycle.

Hysteroscopy Observe then? hysteroscopy

 ABNORMAL
UTERINE BLEEDING

1/ Menorrhagia 2/ Irregular 3/ Postmenopausa

Bleeding Bleeding

2a <40years 2b >40 years

old old
 ABNORMAL
UTERINE BLEEDING

1/ Menorrhagia 2/ Irregular 3/ Postmenopausa

Bleeding Bleeding

2a <40years 2b >40 years

old 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/ Postmenopausa

Bleeding Bleeding

2a <40years 2b >40 years

old 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 cycl
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 spottin
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 we
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 month
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.