Gynaecological bleeding

1. Abnormal uterine bleeding

2. Postmenopausal bleeding

3. Prepubertal vaginal bleeding

4. Contraceptive side effects

Stefan Gebhardt gsgseb@sun.ac.za

Normal menstrual cycle

0 14 28

Estradiol

Progesterone

LH

Anovulation

0 14 28

Estradiol

Progesterone

LH

FSH

Gynaecological bleeding

• Estrogen withdrawal

• Estrogen breakthrough

• Progesterone withdrawal

• Progesterone breakthrough

Estrogen withdrawal

• After oophorectomy

• After withdrawal of exogenous

estrogens

• Midcycle

Estrogen withdrawal

Estrogen breakthrough

• Constant low doses- prolonged, intermittent

spotting

• Sustained high levels of estrogen- prolonged

periods of amenorrhoea followed by profuse

bleeding

Estrogen breakthrough

Progesterone withdrawal

• Removal of corpus luteum (normal

menstruation)

• Discontinuation of progesterone treatment (eg

Riley test)

– Only if endometrium proliferated by estrogen

Progesterone breakthrough

• Only in the presence of unfavourably

high ratio of progesterone to estrogen

– eg long-acting progesterone only

contraception (Depo Provera, Nur Isterate

etc.) or oral contraception

1. Abnormal uterine bleeding

• Dysfunctional uterine bleeding

– No specific cause found

– Failure to control with hormonal therapy

excludes diagnosis

• =often anovulatory

Diagnosis

• Medical and gynaecological history

• Pregnancy test

• Gynaecological examination

Management on clinical findings

• Women 20-35

• Normal weight

• No clear risk factors for STI

• No signs of excess androgens

• Not using any hormones

• No abnormal findings

Treatment

Progesterone therapy

• Medroxyprogesterone acetate (Provera)

or Norethisterone (Primolut-N) 10 mg

per day for 10-20 days per month

• Oral contraception if desired

Treatment

Oral contraception

Low dose combination monophasic

• Brevinor Nordette Femodene

• Minulette Melodene Minesse

• Mirelle Marvelon Mercilon

Treatment

Progesterone therapy

• If progesterone does not correct

bleeding, do further diagnostic

procedures

Diagnostic procedures

• Pelvic ultrasound

• Endometrial sampling

• D&C

• Clotting profile

• Hysteroscopy

Treatment

Estrogen therapy

• Prolonged bleeding, progesterone therapy,

thin endometrium (ultrasound)

• Conjugated estrogen (Premarin 1.25mg) daily

for 7-10 days, followed by Estrogen +

progesterone (Provera 10 mg daily) for 7 days

Treatment

Estrogen therapy

• High doses of estrogen temporarily

stops most dysfunctional bleeding

• Conjugated estrogen (Premarin

1.25mg) daily for 7-10 days

Treatment- emergency

Estrogen therapy

• Conjugated estrogen (Premarin 1.25mg) 6

hourly for 24 hours, followed by 1.25 mg daily

for 7-10 days, followed by combination E+P

• Or 25 mg Premarin IV every four hours until

bleeding stops (+ resuscitation)

Treatment- other modalities

• Antifibrinolytic drugs

– Tranexamic acid (Cyklokapron)

1g 3-4x/day for 1st four days of cycle

• Nonsteroidal anti-inflammatory drugs

– 1st four days of cycle

Treatment- other modalities

• Medicated intra-uterine system (Mirena)

reduce blood loss in menorrhagia

• Danazol (side-effects- do not use)

• GnRH analogues (eg Zoladex) < 6

months (expensive, side effects)

Treatment- special cases

• Patient >35-40 years- always do

diagnostic procedures before starting

therapy

• Polyps, miomas, hyperplasia,

endometrial or cervical cancer etc

Treatment- special cases

• Adolescents- usually anovulatory

• Can be conservative (reassurance,

counseling, menstrual calendar)

• Hormone therapy

Treatment- surgical

• Endometrial ablation

• Hysterectomy

2. Postmenopausal bleeding

• Menopause: diagnosis retrospective• Postmenopausal bleeding: any vaginal

bleeding (even bloody discharge) after at least 6 months amenorrhoea, at the age of the menopause

• Malignant until proven otherwise• Menstruation after 55/ abnormal

menstruation ominous

• Atrophic vaginitis (most common)

• Hyperplasia

• Polyps

• Exogenous estrogens (HRT)

• Malignancy (endometrial, cervical, vagina etc)

• Other: trauma, bladder, rectum

CAUSES

• History

• Clinical examination

• Cytology smear

• Ultrasound

• Histology

Management

Postmenopausal bleeding

VCE smear

Cytology

V C E

Ultrasound

Ultrasound: atrophy

•Thickness: 4mm or less (5mm)

•Regular

•No fluid collections

Ultrasound: histology

•Thickness: >4mm

•Irregular

•Fluid collections (cone biopsy!)

Histology

•Office procedure (Accurette, Pipelle, etc)

•Formal dilation and curettage (differential, DD&C)

Management

•Atrophy

•local estrogen cream for one month

•hormone replacement therapy

Management

•Malignancy

•refer to gynaecologist/ oncologist

• Simple hyperplasia Risk for Carcinoma

– without atypia 1%– with atypia 8%

• Complex hyperplasia– without atypia 3%– with atypia 29%

Endometrial hyperplasia

Management

•Hyperplasia: without atypia

•continuous progesterone treatment (e.g. medroxyprogesterone acetate 5 mg daily for three months) followed by repeat histology

•if normal then, consider hormone replacement therapy

Management

•Hyperplasia: with atypia

•Total abdominal hysterectomy and bilateral salpingo-oophorectomy advised

•Polyps: remove with D&C (histology)

3. Prepubertal vaginal bleeding

• Precocious puberty (breasts <8 years; menarche

<9 years)

• Foreign bodies (offensive discharge)

• Vaginitis (atrophic)

• Tumours (cervix, vagina, uterus)

• Accidental ingestion of hormones (Mother)

Prepubertal vaginal bleeding

• Assessment of secondary sexual

characteristics

• Proper examination (anaesthesia if

necessary)

• Treat cause

Prepubertal vaginal bleeding

• Precocious puberty (breasts <8 years; menarche <9 years)

– Refer to endocrinologist

• Foreign bodies (offensive discharge)

– Remove

• Vaginitis (atrophic)

• -Estrogen cream + antibiotics

• Tumours (cervix, vagina, uterus)

– Refer to oncologist

• Accidental ingestion of hormones (Mother)

• -Conservative

4. Abnormal bleeding on contraceptives

• Satellite symposium: Update in Family Planning

• 23 August 2002

• Bellville Park Campus + 23 other venues in South

Africa

• Enquiries Judy Geldenhuys tel 938 4504

4. Bleeding on contraceptives

• Slight bleeding– exclude pathology (ectopy, polyps)

– reassure

– bleeding only needs treatment if it persists or is excessive

4. Bleeding on contraceptives

• Bleeding shortly after commencement of depo MPA– repeat another 150-300 mg

– only instance where this approach will work

– based on inadequate endometrial suppression

4. Bleeding on contraceptives

• Bleeding after long-term use of depo MPA– Usually due to atrophic endometrium

– Exclude pathology

– Add estrogen 20 microgram po, daily for three weeks/month x2-3 months (+ continue Depo)

4. Bleeding on contraceptives

• Breakthrough bleeding on oral contraceptives– Exclude pathology– In first half of cycle- usually due to insufficient

estrogen stimulation– Minor bleeding- continue pill and wait– Change to pill with higher estrogen content if

bleeding persists (eg Biphasil)– Regard severe breakthrough bleeding as a

menstruation and start a new packet

4. Bleeding on contraceptives

• Breakthrough bleeding on oral contraceptives– In second half of cycle- usually due to

insufficient progestogen stimulation

– Change to pill with higher progestogen content (eg Nordiol, Ovral, Norinyl)

Thank you

• gsgeb@sun.ac.za

• www.sun.ac.za/obs