Management of Abnormal Bleeding in Young Women Mr

Management of Abnormal Bleeding in Young Women Mr Ash Alam Consultant in Obstetrics & Gynaecology Arrowe Park Hospital Wirral 2 nd July 2018 #PROUD TO CARE FOR YOU wuth. nhs. uk @wuthnhs #proud

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Case History: 44 yrs old, Travel Agent, P 2, just returned from Mauritius • Admitted under surgeons with D&V • Slight improvement with fluids/antiemetics • Referred to gynae as PVB • LMP 3 weeks ago • condoms #PROUD TO CARE FOR YOU wuth. nhs. uk @wuthnhs #proud

Pregnant? Normal pregnancy Miscarriage Ectopic pregnancy Molar pregnancy #PROUD TO CARE FOR YOU wuth. nhs. uk @wuthnhs #proud

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Cervical Screening changes HPV vaccine – • Introduced 2008 12/13 yrs & catch up 14 -18 – 86% uptake • bivalent/quadrivalent (70%) • nine valent (90%) • Increase in women>60 (9. 4 m 2012 -12. 1 m 2037) Primary HPV testing • 2019 • Prevent further 24% cervical Ca/year • Decreasing screening – 75. 7 -72. 7 (2011 -2016) #PROUD TO CARE FOR YOU wuth. nhs. uk @wuthnhs #proud

#PROUD TO CARE FOR YOU Castonon et al, Lancet PH vol 3 Jan 18 wuth. nhs. uk @wuthnhs #proud

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#PROUD TO CARE FOR YOU wuth. nhs. uk @wuthnhs #proud ACCS - Clinical Practice Guidance for then Assessment of Young Women Aged 20 -24 with Abnormal Vaginal Bleeding

History – PCB or IMB? : LMP Length of bleeding Type of bleeding Smear history Contraceptive history Other symptoms – pain/discharge/menorrhagia #PROUD TO CARE FOR YOU wuth. nhs. uk @wuthnhs #proud

Examination? : • If there are other symptoms such as pain, dyspareunia, or postcoital bleeding. [& bimanual ] • For persistent bleeding beyond 6 -8 weeks • For new symptoms or a change in bleeding after 6 -8 weeks of contraceptive use • If a woman has not participated in an NHSCSP • If requested by a woman • After a failed trial of the limited medical management available • #PROUD TO CARE FOR YOU wuth. nhs. uk @wuthnhs #proud

Examination findings: Suspicious cancer – 2 week rule Abnormal – eg polyp – routine gynae Normal – preg test/infection screen #PROUD TO CARE FOR YOU wuth. nhs. uk @wuthnhs #proud

Contraceptive issues: Combined Oral – • D’s – • Default/missed pills • Drugs & tobacco • Disturbance of absorption • D&V • Duration • Try not to change if <3/12 and no other problems • May have lighter bleeds with E 2 than EE #PROUD TO CARE FOR YOU wuth. nhs. uk @wuthnhs #proud

POP: • Bleeding may not settle with time (may be less with LNG) • DSG-only POP after 12 months of use 5 in 10 women can expect to be amenorrhoeic or have infrequent bleeding 4 in 10 women can expect to have 3– 5 bleeding spotting/episodes (regular) 1 in 10 women can expect ≥ 6 bleeding/spotting episodes (frequent bleeding) 2 in 10 women will experience bleeding/spotting episodes lasting for more than 14 days (prolonged bleeding) #PROUD TO CARE FOR YOU wuth. nhs. uk @wuthnhs #proud

implant: • As a guide, around: 2 in 10 women are amenorrhoeic 3 in 10 women have infrequent bleeding Fewer than 1 in 10 women have frequent bleeding 2 in 10 women have prolonged bleeding 20, 21 In 75% bleeding-spotting days are fewer than or comparable to those observed during the natural cycle, but they occur at unpredictable intervals #PROUD TO CARE FOR YOU wuth. nhs. uk @wuthnhs #proud

IUS: • Bleeding is common • There is a decrease over time in the number of bleeding and spotting days with all doses of LNG-IUS • A 90% reduction in menstrual blood loss has been demonstrated over 12 months of 52 mg LNG-IUS use • At 1 year, infrequent bleeding is usual with the LNG-IUS and some women will be amenorrhoeic • 24% of 52 mg LNG-IUS users are amenorrhoeic at 3 years #PROUD TO CARE FOR YOU wuth. nhs. uk @wuthnhs #proud

copper IUD: • Unscheduled bleeding in 70% of new users within the first 3 to 6 months of use • In one study of 1, 947 first-time Cu-IUD users, 38% rated menstrual pain and 68% rated menstrual bleeding as “more than before using the IUD” in the first 9 weeks of use. • This decreased to 33% reporting more menstrual pain and 49% reporting more menstrual bleeding at 40 weeks of use. • The Cu-IUD has been shown to objectively increase menstrual blood loss by 50%. #PROUD TO CARE FOR YOU wuth. nhs. uk @wuthnhs #proud

Depo: • Bleeding disturbances (spotting, light, heavy or prolonged bleeding) are common. • Around 1 in 10 women may be amenorrhoeic in the first 3 months • Rates of amenorrhoea increase with duration of use and are similar for IM and SC DMPA. • Around 50% or more amenorrhoeic at 12 months 16, 18, 19 #PROUD TO CARE FOR YOU wuth. nhs. uk @wuthnhs #proud

BTB- On COC: Can try – • • • Changing progesterone/gestodene – little evidence Raising estrogen (eg femodene 30/75) – max 35 Phasic pills • Trinovum or synphase • More time to explain • Risk of errors • More expensive #PROUD TO CARE FOR YOU wuth. nhs. uk @wuthnhs #proud

BTB- On POP: • Could try a different POP -may experience different bleeding pattern • No evidence to support the use of two POPs per day to improve bleeding. • Estrogen supplementation or tranexamic acid may help to reduce bleeding in the short term • evidence does not support routine use long term #PROUD TO CARE FOR YOU wuth. nhs. uk @wuthnhs #proud

BTB- On IUS/Implant: • COC (30– 35 μg EE with LNG or norethisterone) can be considered for up to 3 months continuously or in the usual cyclical regimen (unlicensed). • Consider NSAIDS • Consider alternative contraception after 6 months #PROUD TO CARE FOR YOU wuth. nhs. uk @wuthnhs #proud

BTB- copper IUD: In the first 6 months - reassurance and counseling. Non-steroidal anti-inflammatory drugs (NSAIDs): Cochrane review - naproxen, ibuprofen, or mefenamic acid use for a short course (5 to 7 days) during the days of bleeding was effective. prophylactic use does not decrease the discontinuation rate. Tranexamic acid - significantly decreased mean blood loss during treatment in comparison with placebo. Aspirin has not been shown to be effective #PROUD TO CARE FOR YOU wuth. nhs. uk @wuthnhs #proud

BTB- on Depo: In the first 6 months - reassurance and counseling. Amenorrhea does not require treatment - pregnancy should be ruled out. • No evidence that reducing injection interval for DMPA improves bleeding. However, DMPA may be given after a 10 -week interval. • To reduce the duration of bleeding episodes in DMPA users, mefenamic acid 500 mg twice (or as licensed use up to three times) daily or tranexamic acid 1 g four times daily for 5 days may be effective • COC (30– 35 μg EE with LNG or norethisterone) can be considered for up to 3 months continuously or in the usual cyclical regimen (unlicensed). #PROUD TO CARE FOR YOU wuth. nhs. uk @wuthnhs #proud

Other pathology: • FIGO recommend PALM-COEIN • Polyp • Adenomyosis • Leiomyoma • Malignancy/hyperplasia • Coagulopathy • Ovulatory • Endometrial • Iatrogenic • Not otherwise clasified #PROUD TO CARE FOR YOU RCT n=683. Critchley et al, Health Tech Ass 2001; 8(34)iii-iv, 1 -39. wuth. nhs. uk @wuthnhs #proud

Other pathology: Hysteroscopic findings: • premenopausal >40 yrs – – fibroids polyps hyperplasia cancer 36% 11. 5% 1% 1% • premenopausal <40 yrs – – #PROUD TO CARE FOR YOU RCT n=683. Critchley et al, Health Tech Ass 2001; 8(34)iii-iv, 1 -39. fibroids polyps hyperplasia cancer 19% 6% 0% 0% wuth. nhs. uk @wuthnhs #proud

Further investigation? : • Endometrial biospy: • NICE - >45 persistent symptoms/treatment failure • Consider <45 risk factors eg obesity/DM/PCOS • Ultrasound • Structural abnormality suspected eg polyps/fibroids eg mass • IUS low in cavity? #PROUD TO CARE FOR YOU wuth. nhs. uk @wuthnhs #proud

Polyps Cervical or endometrial #PROUD TO CARE FOR YOU wuth. nhs. uk @wuthnhs #proud

Fibroids submucous #PROUD TO CARE FOR YOU wuth. nhs. uk @wuthnhs #proud

Fibroids – contd. • Medical • Hormonal • TAA • Esmya • Surgical • ablation • Myomectomy • UAE • Hysterectomy • Other • Focussed USS, RF ablation #PROUD TO CARE FOR YOU wuth. nhs. uk @wuthnhs #proud

Adenomyosis: Variant of Endometriosis • Difficult to diagnose on USS. MRI better • Can mimic fibroids • Often diagnosed after hysterectomy • Tx similar to endometriosis #PROUD TO CARE FOR YOU RCT n=683. Critchley et al, Health Tech Ass 2001; 8(34)iii-iv, 1 -39. wuth. nhs. uk @wuthnhs #proud

STD’s • Pill takers +ve chalmydia • 13 % spotting as symptom (5% in uninfected) (Krettek et al) • bloodstained discharge due to endometritis #PROUD TO CARE FOR YOU wuth. nhs. uk @wuthnhs #proud

Menorrhagia/DUB Options: Hormonal therapy best for those with an irregular cycle or who require contraception Non-hormonal therapy most suitable for those with regular cycle who do not require contraception Continue treatment indefinitely if symptoms improved #PROUD TO CARE FOR YOU wuth. nhs. uk @wuthnhs #proud

Bleeding diatheses VWD incidence in dysfunctional uterine bleeding. • case-control study 38 patients & 38 controls • von Willebrand factor antigen, von Willebrand factor activity (VWF: Ac) and factor VIII: C • measured on three serial venous blood samples 1 week apart • VWD was diagnosed in five of 38 (13%) patients with menorrhagia and one of 38 (2. 6%) patients with normal menstrual blood loss • medical therapies such as tranexamic acid or nasal desmopressin #PROUD TO CARE FOR YOU Woo et al, Blood Coagul Fibrinolysis. 2002 Mar; 13(2): 89 -93. wuth. nhs. uk @wuthnhs #proud

Bleeding diatheses Consider further testing if: • HMB since menarche • PPH/post op bleeding/post dental bleeding • Frequent epistaxis/gum bleeding/bruising • Family History #PROUD TO CARE FOR YOU Woo et al, Blood Coagul Fibrinolysis. 2002 Mar; 13(2): 89 -93. wuth. nhs. uk @wuthnhs #proud

Caesarian scar niche bleeding: #PROUD TO CARE FOR YOU wuth. nhs. uk @wuthnhs #proud

Trauma/Vaginismus: Cervical ectropion Vaginal trauma Perineal trauma #PROUD TO CARE FOR YOU wuth. nhs. uk @wuthnhs #proud

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