Abnormal Menstrual Bleeding Flashcards
What are the causes of persistent Abnormal Menstrual Bleeding?
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)
What are the recommended investigations for heavy menstrual bleeding?
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)
What are the risk factors for endometrial cancer?
> 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
What is the management of HMB?
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
What are the causes of intermenstrual bleeding?
Ovulation,
STIs,
Endometrial or cervical poylps,
Progesterone only contraception,
Endometrial hyperplasia or malignancy,
C section scar defect
What investigations should be done for intermenstrual bleeding?
UPT +/- serum hCG
STI screen
Consider punch biopsy of the vulva
Smear
USS including endometrial thickness if persistent or exam reveals any abnormalities
What is the management of Intermenstrual bleeding?
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
What are the causes of post-coital bleeding?
STIs,
Cervical ectropion or polyps, Atrophic vaginitis,
Cervical Ca,
Vaginal Ca,
Trauma
What investigations should be done for post-coital bleeding?
UPT +/- serum hCG
STI screen
Consider punch biopsy of the vulva
Smear
USS
Colposcopy if pelvic exam reveals any abnormality
What is the treatment for post-coital bleeding?
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
What are common causes of post-menopausal bleeding?
Endometrial or vaginal atrophy (60-80%),
MHT (15-25%), Endometrial/cervical polyps 2-12%,
Endometrial hyperplasia (10%),
Endometrial cancer (10%), Cervical cancer <1%.
If on tamoxifen with post coital bleeding what tests are required?
Hysteroscopy and pelvic USS
If not recently started on MHT OR >6 months continuous MHT OR unscheduled bleeding if taking cyclical MHT what tests are required urgently?
High priority pelvic USS
If high suspicion of endometrial cancer what tests are required for post menopausal bleeding?
A pipelle and pelvic USS
What are the diagnostic criteria for PCOS?
Rotterdam criteria: 2 of oligomenorrhoea/anovulation; clinical or biochemical hyperandrogenism; polycystic ovaries on USS if >20 yrs old.