ManagementOfAbnormalVaginalBleeding.ppt

1、management of abnormal vaginal bleedingdr maggie thomsonmay 2009look at the problem in 4 different stageso post pubertalo middle reproductive lifeo perimenopausalo postmenopausalpost pubertalmenarche in the uk is about 12.6 yearsit is genetically controlledinitiation of the process involves an inter

2、action with the percentages body fat and genetic determination of the age of onsetearly cycles are in the majority anovulatorymay take 5-8 years before menstrual cycle normality is establishedthe lack of ovulation and lack of production of progesterone leads to endometrial hyperplasia and thus heavy

3、 menstrual loss“metropathia haemorrhagica”post pubertal bleeding problems they are for the vast majority of girls, self limiting therefore, the most important thing in dealing with them is reassurance they will come right in the endsuggested treatment plans:hb 12g/lreassurancehb 10-12g/lcyclical pro

4、gestogens (21 days out of 28)or the combined contraceptive pill suggest stopping these on an annual basis to see if the normal pattern has establishedhb12cm should be offered referral to a specialistinvestigations at secondary care1. history2. abdominal examination3. speculum4. bi-manual examination

5、5. endometrial biopsy: age 45, persistent imb/pcb, treatment failure or ineffective treatment6. ultrasound is first line to identify structural abnormalities7. fibroids: need no.,size and location8. hysteroscopy used if failed eb, scan not helpful and want to see exact location of fibroid (d&c n

6、ot to be used alone)treatment options: pharmaceuticalofirst line: the iusosecond line: otransenamic acid (3 cycles if no help)oanti-prostaglandins (3 cycles if no help)ococothird line:onet, day 5-26 of cycleoinjectable progestogensoother: gnrh analogues (longer than 6/12, add back hrt)treatment opti

7、ons: surgicalo endometrial ablationo first generation: rollerball and tcreo second generation:o novasure (impedance)o thermal balloono mea (microwave)ablation techniquesv used if severe impact on life and no desire to conceivev can be used with small fibroids (3cm, severe impact on quality of life a

8、nd who want to retain uterus and avoid surgeryo fertility is potentially retained, but problem of ovarian failure in over 45smanagement of fibroidso myomectomyo severe impact on life, 3cmo if submucosal, resect with tcre, followed by rollerball (if fertility not an issue)o surgical myomectomyo ferti

9、lity potentially retained, but may be adhesions, recurrence and infection. may also need hysterectomy if bleedshysterectomy for fibroidsoindicated for fibroids 3cm and severe impact on quality of life.opatients should be aware that the operative risks are greater for hysterectomy for fibroids.oroute

10、 should be discussed, but may be difficult to do it vaginally with large fibroids.hysterectomy for hmbo not first line solely for hmb. consider when:v other treatments have failed, are contra-indicated or declinedv desire for amenorrhoeav fully informed woman requests itv no desire to retain uterus

11、and fertilitytotalsubtotal?lavhrisksremoval of ovaries at hysterectomyvstill produce androgens after the menopausevrisk of ovarian ca lifetime is 1%vafter hysterectomy it is 0.1%vremoval of ovaries gives you 1 more day of life compared to non-removalveven if you take them out, risk of ovarian ca rem

12、ains in the peritoneumvalthough may be more difficult to remove afterwards, not a justification to do sovalways problems for some with ertrecommended .ukcopyright 2005 bmj publishing group ltd.reid, p. c et al. bmj 2005;330:938-939number of hysterectomies for menorrhagia from 1989

13、-90 to 2002-3 in nhs trusts in englandperimenopausal bleeding problemsothey are similar in causation to those who are post-pubertal.oinvestigations are as for hmb/imb in those aged 45 and aboveothe difference is that the risks of malignancy are much highervcervixvhyperplasia (atypical)vendometrial c

14、avendometrial polyps are more commonvand: the length of time for the problem to persist is obviously less!management of perimenopausal bleeding problemso reassurance if no pathology foundo hrt if bleeding problems associated with menopausal symptoms (femoston 2:20)o cyclical progestogens, for 3 week

15、s out of 4. eg. net, provera and dydrogesteroneothe ius advantages of the iuso longer term solution if requiredo fewer systemic side effects compared to oral rx (no increased risk of vte)o can be used in fibroids as long as not submucosalo can be part of hrto amenorrhoea welcomed at this stage of re

16、productive life, without the need for surgerypmbo 10% of cases of pmb will be caused by ca endometriumo the use of hrt has increased the uncertainty as to what constitutes unscheduled bleeding requiring referral for investigationo tamoxifen use has increased for breast ca and is associated with a 3-

17、6x fold increase in the risk of endometrial caall women with pmbo “the risk of endometrial cancer in non-hrt users complaining of pmb and in hrt users experiencing abnormal bleeding is sufficient to recommend referring patients for investigation”what is “abnormal” bleeding in women on hrt?o sequenti

18、al regimes:o may be heavy or prolonged at the end of or after the progestogen phase, oro occur at any time (btb)o continuous combined regimes:*o it occurs after the first 6 months of treatment, oro it occurs after amenorrhoea has been established*far more likely if started too early“if referred to t

19、he gynaecologist, an examination is not always necessary”o “however, examination by gp or practice nurse can alter the course clinical management if it expedites referral on grounds of raised suspicion of a malignancy”investigation of pmbo “where sufficient local skills and capacity exist, tvs is th

20、e first-line procedure to identify which women with pmb are at higher risk of endometrial cancer”an endometrial thickness of 3mm can be used to exclude endometrial cancer in women who:have never used hrt, or;have not used any form of hrt for 1 years, or;are using continuous combined hrt. 3mm 3mmpost-test risk: 0.6-0.8%post-test risk: 20-22%estimated pre-test risk of ca: 10%an endometrial thickness of 5 mm can be used to e