How to apprach case of abnormal vaginal bleeding


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Undergraduate course lectures in Gynecology ,prepared by Dr manal Behery ,assistant professor,faculty of medicine,Zagazig University

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How to apprach case of abnormal vaginal bleeding

  1. 1. How to approach a case ofabnormal Vaginal bleedingDR;MANAL BEHERYAssistant Professor, Zagazig University2013
  2. 2. DefinitionAny uterine bleeding that is excessive inamount ,duration or frequancy
  3. 3. classificationOrganicSystemicReproductive tract diseaseIatrogenicDysfunctionalOvulatoryAnovulatory
  4. 4. Systemic EtiologiesCoagulation defectsLeukemiaITPThyroid dysfunctionLiver disease
  5. 5. Reproductive Tract CausesGestational eventsMalignanciesBenignAtrophyLeiomyomaPolypsCervical lesionsForeign bodyInfections
  6. 6. Most Common Causes ofReproductive Tract AUBPre-menarchalForeign bodyReproductive ageGestational eventPost-menopausalAtrophy
  7. 7. Iatrogenic Causes of AUBIntra-uterine deviceOral and injectablesteroidsPsychotropic drugs
  8. 8. Dysfunctional causesDysfunctional uterine bleeding isthe most commomAfter pubertyBefore menopauseAfter labor or abortion
  9. 9. A practical approach (step 1)History:• Age(before puberty, reproductive age,PM)• Pattern of bleeding: cyclic or a cyclic• Marital state: complication of pregnancy• Drug intake ,hormonal ttt, HRT• previous treatment• last cervical smear
  10. 10. A practical approach (step2)Physical examination• General: obesity? thyroid? pallor?pulse? Cachexia?• Abdomen: palpable mass?• Pelvis: cervical or vaginal lesion?• Bimanual exam:uterine size• Speculum :cervical lesion• PR: rectum or parametrium
  11. 11. A practical approach(step 3)investigationAssessment of the endometrium (not needed forwomen with very low risk of Ca endometrium)• endometrial aspirate• ultrasound pelvis (transvaginal) to assessendometrial thickness• Sonohystrography• Hysteroscopy• CT ,MRI for endometrial invasion
  12. 12. REFER (for endometrialaspiration and TVS if1. Over 40 years2. high risk of endometrial carcinoma3. genital tract lesion suspected (exceptcervical polyp)4. bulky uterus5. previous medical treatment fail
  13. 13. If none of the above factorsConsider those investigationscervical smear if sexually active andlast smear more than 1 year agoCBC if menorrhagiaultrasound pelvis if PV not possibleThyroid function, coagulation profileonly when history suggestive
  14. 14. A practical approach (step4)medical tttFor women under 40 with no suspicion oforganic lesions eitherHormonal (for irregular bleeding as wellas menorrhagia)combined OCprogestogen only (21 days needed)Non-hormonal (for menorrhagia)NSAIDantifibrinolytic agent
  15. 15. Choice of medical treatment formenorrhagiaNSAID: 30% decrease in blood loss ,relievedysmenorrhoea as wellAntifibrinolytic (transamine): 50% decreaseCombined OC: effective but need to take throughout the month, effective contraception as wellProgestogen only: less effective, need 21 days, noteffective contraceptionHaematinics: if anaemiccombinations can be used
  16. 16. When to consider medicaltreatment as failure?• Failure to relieve patient’s symptomsafter 3 months• Remains anemic after 3 months
  17. 17. Step 5 When to refer?• Over the age of 40• High risk of endometrial Cancer(obesity, DM, PCOD)• Uterus > 10 week size or irregular• Cervical pathology suspected• No response to medical treatment
  18. 18. Other modalities of treatmentLevonorgesterol releasing IUCD (Mirena)Endometrial ablationHysteroscopic removal of polyps orsubmucous fibroidsConventional treatment is hysterectomy
  19. 19. Case1A 15 year old girl with irregular heavyperiods presents at your clinic.menarche at the age of 13 and since thenis having unpredictable irregular periodswith prolonged bleeding every 2-3months.She is slightly overweight for her height.
  20. 20. Most likely diagnosis?Anovulatory Dysfunctional uterine bleeding thecommonest cause in 95%Initial cycles are anovulatoryRegular ovulation takes 1-2 years
  21. 21. DifferntionalDiagnosisDysfunctional bleedingBleeding disorders -ITP,VWD etcEndocrine causesMedicationsLocal pathology -TB, FB, malignanciesNo further significant features are foundon history or clinical examination.What is the next step?
  22. 22. InvestigationsHaematological Full blood count and peripheralsmear Platelet count Coagulation screen If indicatedEndocrine TFT, PRLUltrasound
  23. 23. What if anovulatlon persistsfor more than 4 years-chance of spontaneous correction islowLikely to be frank PCOS
  24. 24. Case2A 34 year old lady complaining ofincreasingly heavy periods since thelast one year attends your clinic.She has two children 10 and 8 yearsand underwent laparoscopicsterilization 4 years back.She finds that the bleeding is so heavythat it interferes with her daily routine
  25. 25. Case cont,History of regular heavy periodsSpeculum and bimanual examinationnormalRecent cervical smear normalHb level 9 gm/ 100 nil
  26. 26. What is the next stepOrganic pathology to be ruled out (Fibroidsand adenomyosis (Rule out Pregnancy complicationsRule out endometriosis and pelvic Infection
  27. 27. IS coagulation profile andendocrine panel a routine?Testing for endocrine problems andbleeding disorders not routinelyrecommendedunless there are specific pointers inthe history
  28. 28. Is routine D&C or endometrialsampling needed?Not Indicated this age as first line managementIf a woman has regular cyclesProbability of an abnormal endometrial histologyin a woman under 40 with DUB and regularcycles is <1%
  29. 29. Indication for first lineendometrial samplingIrregular periods with obesity and otherfeatures of PCOS as they are candidatesat high risk for endometrial cancer at ayoung ageRisk of cancer increases to 14%
  30. 30. What is the mostlikely diagnosisOvulatory DUB orIdiopathic menorrhogia
  31. 31. What next?Confirm diagnosis or Idiopathic menorrhagiaCheck for cycle irregularity, Intermenstrual or, postcoltalbleedingWoman With failed first Iine medical management aremore Iikely in have intrauterine pathology and so TVSarid If needed hysteroscopy and endometrial samplingare Indicated (RCOS guidelines)
  32. 32. TVSpolypssubmucous fibroidsEndometrial hyperplasia An endometrialThickness of 12 mm is used as the cut offpaint for endometrial hyperplasia on TVS(RCOG)Optimal time !s the proliferative phase.
  33. 33. SonohysterographyTVS may miss small polypsDifficult to distinguish from thickenedendometriumSHG helps in accurate diagnosis
  34. 34. EndometrialsamplingAll women with persistent menorrhogiaTo diagnose or exclude endometrialcarcinoma or hyperplasiaProbability of abnormal histology < 1 %in this age with regular cycles
  35. 35. Sampling How?Endometrial aspirationConventional D&CHysteroscopy and directed biopsy
  36. 36. Case3A 47 year old woman gives a 2 yearhistory of irregular periods.She has always had regular cycles until3 years ago.She has three children all deliverednormally.
  37. 37. Case cont, No significant finding in the histor On examination she is a little overweight Not anaemic Pelvic examination reveals a normal sizedanteverted mobile uterus Cervical smear is normal
  38. 38.  Anovulatary dysfunctional bleedingCommon at the extremes of reproductive lifeBut malignancy is to be ruled outEndometrial sampling a must to detectendometrial carcinoma and hyperplasiaWhat is the likely diagnosis?
  39. 39. The approach to DUB differs in the different agegroups and in particular depends on whether thebleeding is cyclical or not.The current RCOG recommendations inpremenopausal women with regular cycles is todelay endometrial sampling till medicalmanagement has failed.Also the numbers of hysterectomies being done fornormal sized uteri are coming down withIncreasing acceptance of Mirena and endometrialablation
  40. 40. Case 4Mrs. JP Age 56 Para 1,Complains of aperiod that has been “going on for 2weeks” with painWHAT ARE THE POSSIBLE CAUSES?
  41. 41. Mrs. JP DifferentialDiagnosisEndometrial Pathology Carcinoma Benign eg PolypCervical PathologyOther genital tract pathology Ovarian Ca TraumaDysfunctional Uterine BleedingBlood dyscrasia
  42. 42. what additional informationdo you require?Usual menstrual patternRecent menstrual cycles and LNMPEstimate of blood lossDescription of the painUse of hormones - COC or HRTPap & Gynae HistoryRisk factors for endometrial CaSexual, contraception & social history
  43. 43. Mrs. JP AdditionalHistoryUsual cycleRecent cycles & LNMPEstimate of blood lossDescription of the painUse of hormones - COCor HRTPap & Gynae HistoryRisk factors forendometrial CaSexual history etc.Monthly until 6m agoSome early and some late.Skipped one month. This period3w lateHas used 3 packets pads, some3’’ clots. “Flooding”“Like labour”NilRegular Paps – NAD. One CSand postpartum curette. Tookpill for 10 yrs then separatedInfertility. Hypertension. ObeseCelibate since separation
  44. 44. What Physical Exam Requiredfor this patient?Signs of anaemiaSigns of endocrinopathy Thyroid Androgen excessExamine the cervix ?Pap or ThinPrep Look for cervical mucous Is the cervix open?Uterine size and regularityPelvic tenderness or adnexal mass?
  45. 45. Result of Physical ExamSigns of anaemiaSigns of endocrinopathy Thyroid Androgen excessExamine the cervix ?Pap or ThinPrep Look for cervical mucous Is the cervix open?Uterine size andregularityPelvic tenderness oradnexal mass?Pale. PR 96/minMale type hairdistributionIntact but patulous withabundant clear mucousNADNAD
  46. 46. DO YOU SEND THISPATIENT FOR SCAN?YesBoth transabdominal and transvaginalscan is required
  47. 47. Mrs. JP Scan Report“. Abdominal and transvaginal scans were performed.The uterus is enlarged by multiple fibroids the largestof which measures 2.5 cm in diameter. However,there is no distortion of the endometrial cavity whichmeasures 17 mm.. The right ovary is mildly enlarged with a volume of 40cc and the left ovary contains a cyst measuring 2.8 x2.7 cm.This was evaluated with colour Doppler and noabnormal vascularity noted.”
  49. 49. Mrs. JP PathologyResultsHB 90 Microcytic and hypochromic filmS. Ferritin – 5Pap smear + ThinPrep NAD “but only scantysquamous cells are presentTSH - normal
  50. 50. what would you prescribe forthis patient?Rx Tabs Primolut 5 mg TDS for 10 daysFerro-tonic– one dailyMaybe Nurofen 1-2 Q4-6H
  51. 51. Abdominal CT scan?Immediate D&C?Hysteroscopy?Saline sonography?Endometrial biopsy?Hysterectomy?NoThere are better optionsThis is one that can beperformed as an outpatientMaybe – but best for delineatingpolypsPipelle endometrial sampling isthe best optionOnly required if cancer of theendometrium is diagnosedDoes this patient require?
  52. 52. Case 5A 66-year-old nulliparous woman whounderwent menopause at 55 years complainsof a 2-week history of vaginal bleeding.Prior to menopause she had irregularmenses. She denies the use of estrogenreplacement therapy.Her medical history is significant for diabetesmellitus controlled with an oral hypoglycemicagent.
  53. 53. On examination90kg weight , height 5 ft,blood pressure 150/90 mm Hg, andtemperature is 99°F (37.2°C).The heart and lung examinations are normal.The abdomen is obese, and no masses arepalpated.The external genitalia appear normal, andthenormal sized uterue without adnexal masses
  54. 54. ➤ What is the next step?Perform an endometrial biopsy.➤ What is your concern?➤ Concern: Endometrial cancer
  55. 55. A 60-year-old woman presents to herphysician’s office with postmenopausalbleeding. She undergoes endometrialsampling, and is diagnosed with endometrialcancer.Which of the following is a risk factor forendometrial cancer?A. MultiparityB. Herpes simplex infectionC. Diabetes mellitusD. Oral contraceptive useE. Smoking
  56. 56. A 48-year-old healthy postmenopausalwoman has a Pap smear performed,whichreveals atypical glandular cells. She does nothave a history of abnormal Pap smears.Which of the following is the best next step?A. Repeat Pap smear in 3 monthsB. Colposcopy, endocervical curettage,endometrial samplingC. Hormone replacement therapyD. Vaginal sampling
  57. 57. A 57-year-old postmenopausal woman withhypertension, diabetes,and a history of PCOcomplains of vaginal bleeding for 2 weeks.The endometrial sampling shows a fewfragments of atrophic endometrium.Estrogen replacement therapy is begun.The patient continues to have severalepisodes of vaginal bleeding 3 months later.
  58. 58. Which of the following is the bestnext step?A. Continued observation and reassuranceB. Unopposed estrogen replacementtherapyC. Hysteroscopic examinationD. Endometrial ablationE. Serum CA-125 testing
  59. 59. A 52-year-old woman, who has hypertensionand diabetes, is diagnosed with endometrialcancer.Her diseases are well controlled. Herphysician has diagnosed the condition astentatively stage I disease (confined to theuterus).
  60. 60. Which of t e following is the mostimportant therapeutic measure inthe treatment of this patient?A. Radiation therapyB. ChemotherapyC. Immunostimulation therapyD. Progestin therapyE. Surgical therapy
  61. 61. THANK YOU