Abnormal Menstrual Bleeding

Question 1

What are the causes of persistent Abnormal Menstrual Bleeding?

Answer 1

Ovulatory
Vulval or labial (herpes, genital warts)
Vaginal (atrophic vaginitis, adenosis, tumours, trauma, foreign body, sexual abuse)
Cervical (cervicitis, cervical ectropion associated with contraception, cervical polyps, cancer)
Endometrial (Ca, fibroids)
Leiomyoma (fibroids)
Coagulopathies
Adenomyosis (uterine tissue growing in the uterus wall)

Question 2

What are the recommended investigations for heavy menstrual bleeding?

Answer 2

UPT +/- serum hCG
CBC including ferritin
TSH
Coag and LFTs if hx suggests haemostasis defect (freq nose bleeds, easy bruising, HMB from menarche, FHx)
Pipelle – to rule out endometrial hyperplasia
STI screen
Consider punch biopsy of the vulva
Smear
Pelvic USS including endometrial thickness (if suspect a structural cause; rare <40yrs)

Question 3

What are the risk factors for endometrial cancer?

Answer 3

> 45 yrs, or >35yrs and BMI >30, diabetes, HTN, exposure to unopposed OE2, nulliparity, infertility, PCOS, Maori/PI, FHx endometrial Ca, CRC, SI Ca, Ureter or renal Ca; taking tamoxifen

Question 4

What is the management of HMB?

Answer 4

Fibroids < 3cm Mx by GP with Mirena, COC with >30/35mcg ethinylestradiol if wanting to be pregnant in the near future, Depot, TXA, cyclical progesterones (no contraception, least effective) days 5-25, NSAIDs

Question 5

What are the causes of intermenstrual bleeding?

Answer 5

Ovulation,
STIs,
Endometrial or cervical poylps,
Progesterone only contraception,
Endometrial hyperplasia or malignancy,
C section scar defect

Question 6

What investigations should be done for intermenstrual bleeding?

Answer 6

UPT +/- serum hCG
STI screen
Consider punch biopsy of the vulva
Smear
USS including endometrial thickness if persistent or exam reveals any abnormalities

Question 7

What is the management of Intermenstrual bleeding?

Answer 7

If using COC, consider increasing the ethinyloestradiol dose (to max 35mcg) or change the type of progesterone
If COC running packs together stop for 4 days then resume
Can be common to have unpredictable bleeding with progesterone only pills and it doesn’t always settle over time
Refer to gynae if Ix normal and still an issue

Question 8

What are the causes of post-coital bleeding?

Answer 8

STIs,
Cervical ectropion or polyps, Atrophic vaginitis,
Cervical Ca,
Vaginal Ca,
Trauma

Question 9

What investigations should be done for post-coital bleeding?

Answer 9

UPT +/- serum hCG
STI screen
Consider punch biopsy of the vulva
Smear
USS
Colposcopy if pelvic exam reveals any abnormality

Question 10

What is the treatment for post-coital bleeding?

Answer 10

Depends on the cause e.g.
Atrophic vaginitis: vaginal lubricants or topical vaginal oestrogens
Remove any cervical polyps (GP if <1.5cm; otherwise refer gynae)
If results abnormal, persistent or recurrent post coital bleeding refer for colposcopy

Question 11

What are common causes of post-menopausal bleeding?

Answer 11

Endometrial or vaginal atrophy (60-80%),
MHT (15-25%), Endometrial/cervical polyps 2-12%,
Endometrial hyperplasia (10%),
Endometrial cancer (10%), Cervical cancer <1%.

Question 12

If on tamoxifen with post coital bleeding what tests are required?

Answer 12

Hysteroscopy and pelvic USS

Question 13

If not recently started on MHT OR >6 months continuous MHT OR unscheduled bleeding if taking cyclical MHT what tests are required urgently?

Answer 13

High priority pelvic USS

Question 14

If high suspicion of endometrial cancer what tests are required for post menopausal bleeding?

Answer 14

A pipelle and pelvic USS

Question 15

What are the diagnostic criteria for PCOS?

Answer 15

Rotterdam criteria: 2 of oligomenorrhoea/anovulation; clinical or biochemical hyperandrogenism; polycystic ovaries on USS if >20 yrs old.

Question 16

What is the management of PCOS?

Answer 16

Laser/creams/threading/plucking/waxing/electrolysis for excessive undesirable hair
Pharm takes 6-12 months to work
COCP at lowest effective dose 1st line (oestrogen 20-30mcg); if this is ineffective after 6 months add an anti androgen

Question 17

What is the pathophysiology of PCOS?

Answer 17

Reproductive and metabolic features are due to insulin resistance irrespective of BMI which promotes ovarian androgens and reduces SHBG which increases the free and total androgens

Question 18

What are the implications of PCOS?

Answer 18

Fertility reduced due to irregular periods
Anxiety/depression
Eating disorders
Body image issues
Increased CVD risk
Increased diabetes risk independent of BMI
OSA

Question 19

What is the treatment for poor fertility in PCOS?

Answer 19

If <4 cycles per year use medroxyprogesterone acetate to induce withdrawal bleeds if not on COCP

Question 20

What are the monitoring requirements for PCOS CVD risk?

Answer 20

assess lipids at baseline and regularly if BMI >25
Yearly BP, aim for BP <130/85

Question 21

What is the monitoring for diabetes in those with PCOS?

Answer 21

Assess HbA1c in all women at baseline and every 1-3 years depending on risk factors
OGTT recommended if BMI >25, Asian with BMI >23, FHx of IGT or gestational DM, FHx T2DM or high risk ethnicity
OGTT pre pregnancy, with fertility therapy, and at 25-28 weeks gestation
o Use contraception while on GLP-1 agonists or spironolactone (for hirsuitism)
o Metformin not recommended in pregnancy