Intermenstrual bleeding/Post coital bleeding Flashcards
Intermenstrual bleeding/Post coital bleeding:
Approach?
1) Exclude: a) Pregnancy b) STI c) Cervical cancer
2)
Investigate:
a) 1st Episode = conservative management
*if bleeding continues = TV USS (with Endometrial thickness (ET))
b) Anovulatory or PCOS = TV USS (with ET)
3)
USS result
-any result other than below is managed conservatively
- > 12mm premenopausal = Referral (seen within 6 weeks)
- > 5mm perimenopausal = Referral (seen within 6 weeks)
- Focal lesion = Referral (seen within 6 weeks)
- excess fibrinolytic activity 50%
- fibroids 30%
- Polyps 10%
Intermenstrual bleeding/Post coital bleeding:
Timing of USS?
TUV within 5 - 10 days of bleeding
Intermenstrual bleeding/Post coital bleeding:
non hormonal options?
Non hormonal (equivalent to each other)
1) Prostaglandin inhibitors (20 – 49% effective)
• Ibuprofen 400mg TDS – QID for 5 days
• Mefenamic acid 500mg TDS for 5 days
• Naproxen 500mg then 250mg TDS – QID for 5 days
2) Antifibrinolytics (29 – 58% effective)
• Tranexamic acid 1- 1.5g TDS – QID for 4 -5 days
There is no risk of thrombosis as previously thought
Intermenstrual bleeding/Post coital bleeding:
hormonal options?
Hormonal (Superior control)
• LNG IUD 52mg (71 – 94% effective)
• Any COCP (43% effective)
- Qlaira (Oestradiol) $$
- Zoely (Oestradiol) $$
- Valette (Dionogest) $$
- Northisterone 15mg/d 5 – 26 days (83% effective) for max 6 months
- Depot provera
*If no improvement after trying 2 methods in 6 months then refer
Intermenstrual bleeding/Post coital bleeding:
How to categorise causes?
PRIMARY • normal periods but abnormal haemostasis (50%) ANATOMICAL = on USS • Fibroids 30% • Polyps 10% ANOVULATORY • PCOS • Perimenopausal
OR Structural causes (PALM) P – Polyps A – Adenomyosis L – Leiomyoma (fibroids) M– Malignancy or hyperplasia
Non-structural causes (COEIN) C – Coagulopathy O – Ovulatory E – Endometrial I – Iatrogenic N – Not yet classified
OR Think about anatomy and requirements: Ovarian - ovulatory/hormonal Blood supply - coagulation deficiency/malformation Uterine a) Myometrium - neoplasia, fibroids, polyps, adenomyosis b) Endometrium - neoplasia, hyperplasia c) Cervical - neoplasia, trauma, atrophy