Vaginal Bleeding non pregnant and in pregnancy Tim Chang MBBS(SYD), FRANZCOG Gynaecologist, Endoscopic surgeon and IVF Fertility specialist Dr. Christiane Mayer MD, FRANZCOG Obstetrician and Gynaecologist, 139 Dumaresq street Campbelltown Sponsored by
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Vaginal Bleeding non pregnant and in pregnancy Tim Chang MBBS(SYD), FRANZCOG Gynaecologist, Endoscopic surgeon and IVF Fertility specialist Dr. Christiane.
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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 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
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