Dr Kristina Naidoo Consultant Gynaecologist. Menstrual Disorders Defining normality Defining problem...
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Transcript of Dr Kristina Naidoo Consultant Gynaecologist. Menstrual Disorders Defining normality Defining problem...
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How to manage menstrual disorders in general practice and when to refer to secondary care
Dr Kristina NaidooConsultant Gynaecologist
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Menstrual DisordersDefining normalityDefining problemInvestigations Treatment
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Normal menstruationMost menstrual cycles 22 to
35 daysNormal menstrual flow 3 to 7
days Most blood loss occurs
within first 3 daysMenstrual flow amounts to
35ml*In general, most normal
menstruating women use five or six pads or tampons per day.
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Menarche/MenopauseMenarche average age 12.9
Anovulatory cycles 80% in first year, 10% in 6th year
Menopause 42-58 (average 51)
Postmenopausal bleeding > 1 year after the last menses
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Symptoms of AUBHeavy menstrual bleedingIntermenstrual bleeding (IMB)Postcoital bleeding (PCB)Irregular menstrual cyclePostmenopausal bleeding
+/-pain
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FIGO classification of Causes of AUB (non-pregnancy)
PALM-COEINP polypsA adenomyosisL leiomyomaM malignancy & hyperplasiaC coagulopathyO ovulatory disordersE endometrial causesI iatrogenicN not classified
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When to referSuspected cancer- symptoms
PCB lasting more than 4 weeks over 35 yearsIMB persistent and unexplained 1 or more episodes of PMB and NOT on HRTPersistent or unexplained PMB 6/52 after
cessation of HRTAny unscheduled bleeding on Tamoxifen
NOT Repeated, unexplained PCB
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When to refer Suspected cancer- signs
Palpable abdominal/pelvic mass not obviously fibroids/urinary or GI
Lesion on cervix suspicious of cancer
Unexplained vulval lump
Vulval bleeding due to ulceration
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Heavy Menstrual Bleeding(HMB)
Excessive menstrual blood loss which interferes with a woman's physical, social, emotional and/or material quality of life
It can occur alone or in combination with other symptoms
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HMBBlood loss is subjective30% women consider their bleeding to be
excessiveHalf of these have a normal blood loss
(<80ml)Women aged 30-49, 1:20 consults GP re
HMB each yearHMB accounts for 12% of Gynae referrals£7 million a year spent on prescriptions in
primary care (2007)
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Mirena LNG-IUSProvided long-term use (at least 12 months
anticipated)Prevents endometrial proliferation.Contraceptive.Doesn't impact future fertility.Unwanted outcomes: irregular bleeding that can last
for six months; amenorrhoea; progestogen-related problems such as breast tenderness, acne and headaches; uterine perforation at insertion (1 in 100,000 chance).
As equally effective in improving quality of life and psychological well-being as hysterectomy.
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Submucous fibroid and Mirena IUS
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Tranexamic acidOral antifibrinolytic .If no improvement, stop after three cycles.Unwanted outcomes: indigestion; diarrhoea;
headache.No increased risk of thrombosis. Cochrane
review.Dose: 500 mg tablets. 2 to 3 tablets (1-1.5g
three to four times daily for three to four days. From onset of heavy bleeding.
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NSAIDsCommonly used: mefenamic acidReduce production of prostaglandin.If no improvement, stop after three cycles.Preferred over tranexamic acid in
dysmenorrhoea.Unwanted outcomes: indigestion; diarrhoea;
worsening of asthmaDose: mefenamic acid 500 mg tablets. 1
tablet three times daily during heavy bleeding.
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COCPs
Prevent proliferation of the endometrium.Also act as a contraceptive.Do not impact future fertility.Unwanted outcomes: mood change;
headache; nausea; fluid retention; breast tenderness; DVT; MI; CVA.
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Oral progestogenCommonly used: NorethisteronePrevents proliferation of the endometrium.Does not impact future fertility.Dose: 15 mg daily on days 5-26 of the cycle.Unwanted outcomes: weight gain; bloating;
breast tenderness; headaches; acne; depression.A recent Cochrane Review showed that this
regime of progestogen results in a significant reduction in menstrual blood loss but that women find the treatment less acceptable than intrauterine levonorgestrel.
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Injected progestogenDepot-medroxyprogesterone acetatePrevents proliferation of the endometrium.Contraceptive.Does not impact on future fertility.Unwanted outcomes: as for oral progs; weight gain;
irregular bleeding; amenorrhoea; bone density loss.Current guidance:Use in adolescents as last resort. Other women re-evaluate after 2 years, if significant
risk factors for osteoporosis consider alternative.
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When to referSuspicion from history of increased risk of
pathology:
E.g. family history of endometrial or colonic cancer
Infertility/nulliparityObesity/diabetes Unopposed oestrogen therapyPCOS
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‘One stop’ Menstrual Dysfunction ClinicConventional pathway ‘One stop’ pathway
General Gynaecology Clinic ?biopsy
‘One stop’ menstrual dysfunction clinic
Pelvic scan
Review, list for Day Case Hysteroscopy
Pre-operative assessment clinic
Hysteroscopy under GA
Follow-up to plan management
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Outpatient HysteroscopyRCOG
recommendation2012 favourable
tariff Diagnosis of benign
intrauterine pathology
TreatmentResection polyps,
small fibroids, RPOCs
IUD retrieval
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ConclusionsReassurance re normal patterns of bleedingFull blood count -first line investigationLow threshold for pelvic scanning (TVS) Hormonal contraception for HMB
Red flag symptoms-> HSC205 pathwayRisk factors for endometrial pathology->
refer early‘One stop’ clinics advantageous