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Abnormal Menstrual Bleeding - Coggle Diagram
Abnormal Menstrual Bleeding
Definitions
Abnormal Menstrual Bleeding (AUB)
Any vairation from the normal menstrual cycle, including changes in regularity, frequency, duration or amount of blood loss (acute vs chronic)
Heavy Menstrual Bleeding (HMB)
The most common variation of abnormal uterine bleeding
30%
Subjective Definition [NICE, FIGO]
Excessive menstrual blood loss which interferes with the woman's physical social, emotional and / or material quality of life
Symptom not diagnosis
Can occur alone or in combo with other syptoms
Is the main definition used in clinical practice
Objective Definition [ACOG]
Clinician determined
Used in research setting
Menstrual bloos loss >80 ml / cycle
Acute Abnormal Uterine Bleeding
An episode of bleeding from the uterine corpus that in the opinion of a clinician, is of sufficient quantity to require immediate intervention to minimise or prevent further blood loss
May occur in the context or in the absence of existing chronic AUB
Chronic Abnormal Uterine Bleeding
Bleeding from the uterine corpus that: if menstrual is abnormal in regularity, frequency, duration and / or volume
Or is non meanstrual and has been present for the majority of the precending 6 months
FIGO AUB Classification System 1: Symptoms
Normal versus abnormal menstrual bleeding
FIGO provide objective criteria for normal and abnormal menstrual bleeding and should be used
However there is considerable varition in the pattern of menstrual bleeding from woman to woman and it is important to establish what is normal for her
Regularity
Normal
Variation of 4 days or less
Abnormal
Variation of more than 4 days
Frequency
Normal
28-38 days
Abnormal
<24 days
More than38 days
No bleeding
Duration
Normal
≤ 8 days
Abnormal
Over 8 days
Volume
Normal
Normal volume
Abnormal
Light
Heavy - excessive which interferes with QOL
Intermenstrual Bleeding
Vaginal bleeding occuring between cyclically regular mesntrual bleeding
Normal
None
Abnormal
Present
Unpredictable or predictable
Postcoital Bleeding
Non mentrual vaginal bleeding that occurs after sexual intercourse
Normal
None
Abnormal
Present
Breakthrough Bleeding
Unscheduled vaginal bleeding that occurs on progesteron +/- oestrogen medication
Normal
None
Abnormal
Present
FIGO AUB Classification System 2: Causes
PALM
Structural
causes
Diagnoses by imaging / histopathology
P - Polyp
A -Adenomyosis
L - Leiomyoma (fibroid)
M - Malignancy
COEIN
Non structural
causes
Diagnosed by hx or exclusion
C - Coagulation (hx + coag studies)
O - Ovulatory (hx)
E - Endometrial (exclusion)
I - Iatrogenic (hx)
N - Not otherwise classified
There may be more than one cause
May be incidental - asymptomatic
Other
Cervical
Cervical ectropion
Cervicitis
Cervical polyp
Cervical cancer
Vulva / vagina
Urinary / GI tract
Causes
Polyps
Characteristics
Mucosal outgrowth of endometrium
Aetiology unclear - though to be related to oestrogen stimulation
Prevalence unknow - more common in women 40+ (postmenopause)
Symptoms
82% asymptomatic and small
May regress spontaneusly
Abnormal bleeding - polypectomy
Malignant transformation 1%
Higher risk in women with othe risk factors
Adenomyosis
Characteristics
Presence of endometrial tissue in the myometrium, causing hypertrophy of smooth muscle and thicken myometrium
20% of women of reproductive age
Symptoms
Asymptomatic
Pelvic pain
Abnormal bleeding
Diagnosis
USS / MRI
Leiomyoma (Fibroids)
Characteristics
Fibromuscular growths in myometrium which are hormone sesitive
Common - 70-80% of > 50 yr/o
Size varies from mm to full term pregnancy
Symptoms
Postmenopausal bleeding
Abnormal uterine bleeding - particularly intermenstrual bleeding
Abnormal vaginal discharge / haematuria in postmenopausal women
Coagulation
Examples
Bleeding disorder
Von Willebrand disease mainly
Epidemiology
13% of women with HUB
Symptoms
HUB since menarche
Haemorrhage postpartum / post surgery / dental rx
Frequent bruising, epistaxis, gum bleeding
Fhx of clotting disorder
Ovulatory
Examples
Thryroid disorder
PCOS
Characteristics
Anovulatory bleeding - endocrine origin or related to obesity
Symptoms
Irregular cycle
Prolonged bleeding
Interspersed periods of amenorrhoea
Common in puberty and perimenopause
If irregular and no structural or other non structural abnormality - probably AUB-O
Endometrial
Examples
Endometritis
PID due to infection
Characteristics
Disorders of mechanisms regulating local endometrial haemostasis
Symptoms
Heavy or erratic vaginal bleeding
Postcoital bleedin
Pelvic pain and / or dyspareunia
Abnormal discharge
Regular and no structural or other nonstructural cause - probably AUB-E
Iatrogenic
Examples
IUCD - copper IUD
Drugs interfering with ovulation
Anticoagulants
Exogenous hormones - contraception or HRT
Symptoms
Heavy or erratic vaginal bleeding
Not Otherwise Classified
Examples
AV malformations
CS niche
Symptoms
Heavy or erratic vaginal bleeding
Defunct Terminology - Avoid
Menorrhagia
Heavy menstrual bleeding
Metrorrhagia
Intermenstrual bleeding
Polymenorrhoea
Frequent bleeding
Oligomenorrhoea
Infrequent bleeding
Dysfunctional
COIEN
Assessment of AUB
History
Details of mentrual cycle
Frequency
Duration
Volume
REgularity
Post coital bleeding
Intermenstrual bleeding
Associated symptoms
Pain
Dysmenorrhoea
Pressure symptoms
Impact on QOL
Factors impacting Rx decisions
Desire to conceive
Previous tx tried
PMH
Symptoms indicating Need for Blood Transfusion
Dizziness
SOB
FAtigue
Examination / Bedsides
BMI
Raised BMI risk factor for endometrial cancer
PCO
Vitals signs
Pyrexia in PID
Tachycardia in anaemia
Urine pregnancy test
Intrauterine pregnancy
Ectopic pregnancy
Urinalysis
UTI / renal stones may present with pelvic pain and haematuria
Abdominal Examination
Distension with fibroids
Pelvic Exam
Bimanual Exam
Enlarged uterus: Fibroids, adenomyosis
Speculum exam +/- swab
HVS / EC
Cervical abnormalites
Endocervical polyps
Bloods / Imaging
FBC
Coag
If hx of HMB since menarche or personal / FHx of coag disorder
TFTs
If other indicators to do so - hx of thyroid dysfunction
Transvaginal US
If Significant pelvic pain / dysmenorrhoea
If bulky tender uterus on exam suggesting adenomyosis
If enlarged uterus or pelvic mass suggesting fibroids
If inconclusive exam (eg due to obesity)
Refer for Hysteroscopy if:
Endometrial pathology
Submucosal fibroids
Referral to Gynae OPD if:
Large fibroids >3cm
Evidence of adenomyosis or endometriosis - manage medically
Hysteroscopy
If normal physical examin but symptoms suggestive of endometrial pathology
Persistent IMB / irregular bleeding
Hx PCO
Hx Tamoxifen
Obesity
Treatment failure
Managment of HMB
1️⃣ Line
Intrauterine system - LNG-IUDs
2️⃣ Line
Tranexemic acid ( Antifibrinolytic agent)
NSAIDs - Mefenamic acid
Combined hormonal contraceptive ( pill / patch / ring)
Progestogen containing contraceptive ( POP / Implanon /depot)
Cyclical oral progestogens (short cycle vs long cycle)
3️⃣ Line
Endometrial Ablation
Surgery / Hysterectomy
Cyclical Oral Progestogens
Options
• Medroxyprogesterone acetate (Provera) 10mg PO up to TDS
• Norethisterone 5mg PO up to TDS (avoid if risk factors for VTE)
Short cycle progestogens
Taken during luteal phase - 7-10d of a cycle
Long cycle progestogen
Taken 21d of a cycle, from d5-d26
May have a superior role in HMB managment
Endometrial Ablation
MOA
Destruction of endometrial tissue by minimally invasive surgery
First line surgical rx
Techniques
First generation procedures
Hysteroscopically
Rollerball electrocautery
Laser ablation
Transcervical resection (TCRE)
Second Generation Techniques
Blind insertion of device administering microwave, thermal energy or radiowave
Can be carried out LA in OPD
Contraception Post Ablation
Should only be performed on women who have completed their families
Leads to destruction of endometrial tissue, adhesions, uterine distorsion
Pregnancy Risks Post Ablation
Miscarriage
Preterm labour
Placental abnormalities
Foetal abnormalities
Haemorrhage
Contraception must be used post-ablation
Iron supplementation if indicated
Monitor and discontinue when no longer required