Management: bleeding examined€¦ · MENORRHAGIA or dysfunctional uterine bleeding (DUB) were...
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MEDICALOBSERVER.COM.AU MARCH 2017 66 TALKING WOMEN MENORRHAGIA or dysfunctional uterine bleeding (DUB) were terms historically used to describe heavy menstrual bleeding. Heavy bleeding refers to cyclic menses that are prolonged and/or heavy. Affecting one in five women, it is one of the most common forms of abnormal uterine bleeding. Because the terms menorrhagia and DUB were poorly defined and inconsist- ently used, in 2011 new terminology was devised by the International Federation of Gynecology and Obstetrics (FIGO). The revised terminology uses the acro- nym PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia — coagulopathy, ovulatory dysfunction, endometrial, iatrogenic and not yet clas- sified) to guide clinicians through history, examination and investigations. PALM refers to structural abnor- malities and COEIN to non-structural abnormalities. Consultation: Assess medical, gynae- cological and family history, current medications and symptoms of anaemia. Menstrual history should include fre- quency, duration, regularity and volume of period. Heavy bleeding is objectively >80ml for the period, or loss that subjectively causes physical, emotional or social difficulties. Ask about the number of pads or tam- pons used, if bedding or clothing is stained and if menses causes the woman to avoid normal activities. Inquire about pelvic pain or pressure symptoms, difficulties with bowel, bladder or sexual function and previous treatments and outcomes. Examination: Perform a general exami- nation to check for signs of thyroid disease, hyperandrogenism and anaemia. Abdominal palpation might reveal a pel- vic mass (most likely fibroid). Examine vulva, vagina and cervix to rule out lower genital tract causes of bleeding, including cervical swabs and cytology as indicated. Bimanual examination may reveal uterine masses or tenderness. Investigations: Exclude pregnancy, check Hb and iron studies. Other investigations should be carried out as indicated: TSH; endocrine evaluation for hyperandrogenism; coagulation studies. Endometrial sampling is recommended if the patient is older than 45 or at increased risk of hyperplasia/malignancy (prolonged amenorrhoea; obesity; family history). Transvaginal pelvic ultrasound can diag- nose uterine fibroids and suspected polyps. Note that measurement of endometrial thick- ness in premenopausal women is not a useful test, because of the limited correlation between thickness and pathology/treatment outcome. Saline infusion sonography can better assess intra-cavity lesions, and office hysteroscopy can diagnose, sample and potentially treat causes. Management: Non-steroidal anti-inflam- matory drugs (NSAIDS) and antifibrinolyt- ics are first-line non-hormonal agents for use during menstruation. NSAIDs can reduce flow by up to 30% and tranexamic acid by up to 50% when taken three times daily for up to five days of the period. NSAIDs may also pro- vide analgesia. Hormonal treatment is either progestins only (oral, depot IMI, subdermal implant or IUD) or combined oestrogen and progesta- gen (COCP/Nuvaring). Progestins can reduce flow 30% (oral) up to or more than 94% (IUD). COCP can reduce flow up to 50%. Surgical management can include endo- metrial ablation (85% of women have signif- icant menstrual reduction) or hysterectomy. Fibroid removal may be indicated. References at medobs.com.au *Dr Manwaring has a special interest in endometriosis and pelvic pain. She consults at the Royal Women’s Hos- pital and the Mercy Hospital, Melbourne. This column is supplied by Jean Hailes for Women’s Health - a national, not-for-profit organisation focusing on clinical care, innovative research and practical educational opportunities for health professionals and women. www.jeanhailes.org.au The PALM-COEIN acronym ensures a thorough investigation of menorrhagia DR JANINE MANWARING MBBS(HONS), FRANZCOG Gynaecologist, laparoscopic surgeon; Jean Hailes, Epworth Freesmasons* Heavy bleeding examined THINKSTOCK.COM PALM-COEIN classification of abnormal uterine bleeding PALM: Structural Polyp Adenomyosis Leiomyoma Submucosal myoma Other myoma Malignancy & hyperplasia COEIN: Non-structural Coagulopathy Ovulatory dysfunction Endometrial Iatrogenic Not yet classified Abnormal uterine bleeding Heavy menstrual bleeding Intermenstrual bleeding Source: FIGO
Transcript of Management: bleeding examined€¦ · MENORRHAGIA or dysfunctional uterine bleeding (DUB) were...
MEDICALOBSERVER.COM.AU MARCH 2017
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TALKING WOMEN
MENORRHAGIA or dysfunctional uterine bleeding (DUB) were terms historically used to describe heavy menstrual bleeding.
Heavy bleeding refers to cyclic menses that are prolonged and/or heavy. A� ecting one in � ve women, it is one of the most common forms of abnormal uterine bleeding.
Because the terms menorrhagia and DUB were poorly de� ned and inconsist-ently used, in 2011 new terminology was devised by the International Federation of Gynecology and Obstetrics (FIGO).
The revised terminology uses the acro-nym PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia — coagulopathy, ovulatory dysfunction, endometrial, iatrogenic and not yet clas-si� ed) to guide clinicians through history, examination and investigations.
PALM refers to structural abnor-malities and COEIN to non-structural abnormalities.
Consultation: Assess medical, gynae-cological and family history, current medications and symptoms of anaemia. Menstrual history should include fre-quency, duration, regularity and volume of period.
Heavy bleeding is objectively >80ml for the period, or loss that subjectively causes physical, emotional or social di� culties.
Ask about the number of pads or tam-pons used, if bedding or clothing is stained and if menses causes the woman to avoid normal activities. Inquire about pelvic pain or pressure symptoms, di� culties
with bowel, bladder or sexual function and previous treatments and outcomes.
Examination: Perform a general exami-nation to check for signs of thyroid disease, hyperandrogenism and anaemia.
Abdominal palpation might reveal a pel-vic mass (most likely � broid). Examine vulva, vagina and cervix to rule out lower genital tract causes of bleeding, including cervical swabs and cytology as indicated. Bimanual examination may reveal uterine masses or tenderness.
Investigations: Exclude pregnancy, check Hb and iron studies. Other investigations should be carried out as indicated: TSH; endocrine evaluation for hyperandrogenism; coagulation studies.
Endometrial sampling is recommended if the patient is older than 45 or at increased risk of hyperplasia/malignancy (prolonged amenorrhoea; obesity; family history).
Transvaginal pelvic ultrasound can diag-nose uterine � broids and suspected polyps. Note that measurement of endometrial thick-ness in premenopausal women is not a useful test, because of the limited correlation between thickness and pathology/treatment outcome.
Saline infusion sonography can better assess intra-cavity lesions, and o� ce
hysteroscopy can diagnose, sample and potentially treat causes.
Management: Non-steroidal anti-in� am-matory drugs (NSAIDS) and anti� brinolyt-ics are � rst-line non-hormonal agents for use during menstruation. NSAIDs can reduce � ow by up to 30% and tranexamic acid by up to 50% when taken three times daily for up to � ve days of the period. NSAIDs may also pro-vide analgesia.
Hormonal treatment is either progestins only (oral, depot IMI, subdermal implant or IUD) or combined oestrogen and progesta-gen (COCP/Nuvaring).
Progestins can reduce � ow 30% (oral) up to or more than 94% (IUD). COCP can reduce � ow up to 50%.
Surgical management can include endo-metrial ablation (85% of women have signif-icant menstrual reduction) or hysterectomy. Fibroid removal may be indicated. References at medobs.com.au
*Dr Manwaring has a special interest in endometriosis and pelvic pain. She consults at the Royal Women’s Hos-pital and the Mercy Hospital, Melbourne.
This column is supplied by Jean Hailes for Women’s Health - a national, not-for-pro� t organisation focusing on clinical care, innovative research and practical educational opportunities for health professionals and women. www.jeanhailes.org.au
The PALM-COEIN acronym ensures a thorough investigation of menorrhagia
DR JANINE MANWARING MBBS(HONS), FRANZCOG
Gynaecologist, laparoscopic surgeon; Jean Hailes, Epworth Freesmasons*
Heavy bleeding examined
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.COM
PALM-COEIN classification of abnormal uterine bleeding
PALM: Structural PolypAdenomyosisLeiomyoma Submucosal myoma Other myomaMalignancy & hyperplasia
COEIN: Non-structural Coagulopathy Ovulatory dysfunctionEndometrialIatrogenicNot yet classi� ed
Abnormal uterine bleeding Heavy menstrual bleeding
Intermenstrual bleeding
Source: FIGO
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