Unscheduled bleeding in young women Dr Kathryn Hill GPST2 in O+G.

Unscheduled bleeding in young women

Dr Kathryn HillGPST2 in O+G

Aims

To review the guidelines on the management of abnormal vaginal bleeding in young women

To concentrate on the investigation/ management to be carried out before referral to colposcopy clinic

Why is it important?

1/600 women aged 20-24y reported PCB per year

0.5-1% women aged 20-24y present with IMB/ year

Estimated 7500 – 15000 women will present each year

DoH Clinical Practice Guidelines

Women aged 20-24y

Abnormal vaginal bleeding relatively common

To prevent delay of referral to colposcopy in rare cases of cancer

Management - PCB

History Speculum examination If clinically suspicious 2ww If local problem treat or refer If normal for swabs Refer if bleeding persists 6-8 weeks

Women over 35y PCB >4w refer colposcopy (Scottish Guidelines)

Management - IMB

History

If suspected OCP problem – modify contraception

If bleeding persists (6-8 weeks) – speculum

FSRH - management of unscheduled bleeding on hormonal contraception

Frequent / prolonged / irregular / spotting

Many due to method of hormonal contraception

Endometrial and cervical cancer rare

Early vs late symptoms

May not need examination


COCP/ Patch/ Ring:Upto 20% have irregular bleeding in 1st 3mUsually settlesUse lowest oestrogen dose for cycle controlMay need to increase from 20mcg to 30-35mcgNo evidence tricycling settles bleeding

Progesterone onlyBleeding pattern on one method does not predict

bleeding patterns with another method


POP:Early - 30% change in bleeding and 10% irregularLater – 50% regular bleed and 30-40% irregularNo evidence changing type of pill will helpNo evidence that 2 pills per day will help

Injectable:35% amenorrhoeic at 3m and 70% at 1yNo evidence reducing interval improves bleedingMefenamic acid 500mg bd 5d reduced length of

bleeding episode. No long term effect.


Implant:At 6m 30% infrequent and 10-20% prolonged

bleedingDoxycycline may help but limited evidence

IUS:Irregular, light or heavy in 1st 6m65% have amenorrhoea or reduced bleeding at 1yNo evidence for treatment options

Injectable / Implant / IUS:COC upto 3m (usual use or continuous) recommended if not contraindicated

Summary

HistoryConsider examinationConsider investigation for infectionsModify hormonal contraceptionRefer if persistant bleeding for 6-8 week

References

Clinical practice guidance for the assessment of young women aged 20-24 with abnormal vaginal bleeding. DoH Mar2010. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_113553.pdf

Management of unscheduled bleeding in women using hormonal contraception. FSRH May2009. http://www.rcog.org.uk/files/rcog-corp/UnscheduledBleeding23092009.pdf

Persistant PCB. RCOG Query bank. http://www.rcog.org.uk/womens-health/clinical-guidance/persistent-post-coital-bleeding-query-bank

Unscheduled bleeding in young women Dr Kathryn Hill GPST2 in O+G.

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