Abnormal vaginal bleeding Flashcards
Define: menorrhagia, polymenorrhagia, metorrhagia, premenarchia, postmenopausal
Menorrhagia: menstrual blood loss of >80 mL per cycle
Polymenorrhoea: menstruation more frequent than every 3 weeks
Metrorrhagia: abnormal uterine bleeding between menstrual periods
Premenarchal bleeding: vaginal bleeding that occurs before a girl is 9 years old
Postmenopausal bleeding: vaginal bleeding that occurs >12 months after menopause has been established.
Incidence
25%
Common differential
Cervical cancer
Cervical polyp
Ectropion
Thyroid
PCOS
Endometrial polyp
Fibroid
Endometritis
DUB
Menorrhagia
Miscarriage
Other uncommon
EndoM/ovarian/vaginal Ca Cushing \+Prolactin Renal/hepatic failure VWD GTD Ectopic Cervicitis Vaginitis Anticoagulant Contraceptive related
History
Questions may include:
When did symptoms start and how long do they last?
Does the patient think the bleeding is excessive and is it interfering with normal life?
Are there any associated symptoms such as pain, fatigue, dyspnoea on exertion, or unexplained weight loss?
Is there intermenstrual or postcoital bleeding?
What is the possibility of the patient having an STD?
Could she be pregnant? If she is pregnant, does she have any pain associated with the bleeding
Does the patient use contraceptives; if so, which ones and for how long?
What is the result of the last smear test (if she has ever had one)?
Is there a known history of uterine pathology such as leiomyomas (fibroids), endometrial polyps, and adenomyosis (endometrial glandular growth into the myometrium)?
Is the patient taking any medication, such as anticoagulants, corticosteroids, HRT, or herbal supplements?
Does the patient bruise easily, is minor wound bleeding prolonged, and is there a family history of coagulation disorders?
Dysuria, frequency, hematuria?
Hemorrhoids, fissue?
Physical examination
General:
- Anemia
- Hypothyroidism
- PCOS
- Acanthosis nigricans
- Liver disease stigmata
Genital- inspection
Speculum
Bimanual
Investigations
Serum or urine pregnancy bHCG Maternal Rh/antibodies-may require anti-D FBC- anemia, malignancy Blood iron TSH, prolactin, Testosterone/Progesterone/LH, liver- if indicated PT/PTT VWD
?Colposcopy, ?Hysteroscopy
TVUS/TAUS
Papsmear
When is TVUS useful and TAUS
TVUS->ectopic/miscarriage
TAUS->uterine fibroids
Endometrial thickness warranting endometrial biopsy
> 15mm
When is hysteroscopy warranted
Endometrial cavity pathology suspected
Red flags
Cervical cancer Miscarriage PID Endometritis Endometrial Ca Ovarian Ca Vaginal cancer Acute leukemia Lymphoma Ectopic GTD Placental abruption, placenta praevia Endometrial hyperplasia
Medical management for non-pregnancy, repro age women, hemodynamically stable, need urgent control of bleeding
High dose estrogen->acute Medroxyprogesterone->less acute OCPs LNG-IUS GnRH agonist->Leuprolide depot->in prep for surgery Tranexamic acid NSAID- mefenamic acid
Surgical management for non-pregnancy, repro age women, hemodynamically stable, need urgent control of bleeding
D&C->can provide tissue for pathology
Myomectomy
Endometrial ablation
UAE
