abnormal uterine bleeding - gp cme south/workshop - bleeding.pdf · •metrorrhagia and...
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Abnormal Uterine
Bleeding
Richard Dover
Specialist gynaecologist
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A pragmatic guide.
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Wide topic range
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What’s not coming up…
• Precocious puberty
• Menorrhagia
• well maybe just a little
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Topics
• Adolescents
• IMB
• PCB
• PMB
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Terminology
• Confusing
• Amenorrhea
• Oligomenorrhea
• Menorrhagia
• Polymenorrhea
• Metrorrhagia and menometrorrhagia
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“Normal”
• Lasts from 2-7 days
• Cycle varies from 24-35 days
• Less than 80mls
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Amenorrhea
• Absence of bleeding for 3 usual cycle
lengths
• Or 6/12
• Differs from person to person
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Menorrhagia
• Heavy or excessive
• Usually means >80mls
• Never measured
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Oligomenorrhea
• Interval in excess of 35 days
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Polymenorrhea
• Regular bleeding that occurs at an interval
of less than 24 days
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Metrorrhagia &
Menometrorrhagia
• Metrorrhagia. Light bleeding at irregular
intervals
• Menometrorrhagia. Heavy, irregular
bleeding
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Can be confusing
• Probably best to describe what is actually
happening.
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AUB in adolescents
• Is it any different?
• A different normal?
• Development of regular ovulatory cycles
• Primary or secondary amenorrhea
• Importance of PCOS/Turner’s
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Background
• Post-menarche, 50% cycles anovulatory in
the first year
• Median length of first cycle ~34 days
• 38% >40 days
• 7% <20 days
• BUT ~80% lie /21-45
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Specific concerns
• Weight loss / anorexia
• Bleeding / bruising / clotting problems
• Up to 25% may have a bleeding problem
• PCOS and amenorrhoea
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Intermenstrual Bleeding
• Traditionally suggestive of a uterine cause
• Isolated episode?
• Frequent?
• Resolved?
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Management
• Conservative
• Ultrasound
• Endometrial sampling
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Ultrasound
• Transvaginal
• Ovarian lesions
• Uterine size and texture – fibroids
• Endometrial stripe. Regular, polyp?
• Sonohysterography?
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TVS What is normal?
• Proliferative phase 4-8mm
• Secretory phase 8-14mm
• Clearly seen endometrial stripe
• Uniform thickness
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Post-coital Bleeding
• Usually suggestive of a cervical lesion
• Recent onset
• Each time?
• Relation to cycle
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Causes
• Ectropion
• Infective
• Polyps
• Malignant (age, previous smear history)
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Management
• Swabs
• Smear
• DOES THE CERVIX LOOK NORMAL?
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Colposcopy
• If the cervix looks abnormal
• If the smear is abnormal (always?)
• Patient concerned
• Fails to settle?
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Menorrhagia
• Common
• Loss never measured
• How can you quantify the loss?
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Dysfunctional Uterine Bleeding
• Diagnosis of exclusion
• ~60% of hysterectomy specimens will
have no pathological abnormality
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Endometrial sampling
• Those at risk of endometrial hyperplasia
(USA)
• Those over 45
• IMB as well
• Abnormal scan
• Fails to settle with treatment
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Postmenopausal bleeding
• Common
• Incidence related to time since
menopause
• 409/1000 person years within 12/12
• 42/1000 person years after 36/12
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Causes
Atrophy 59%
Polyps 12%
Endometrial cancer 10%
Endometrial hyperplasia 9.8%
Hormone effect 7%
Cervical cancer <1%
Other 2%
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Management
• Aim is to exclude malignancy
• Age and history related (DM HT)
• Single or multiple bleeds
• Previous episodes
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Assessment
• To biopsy, or not to biopsy?
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TVS
• Endometrial thickness >4mm
• Endometrium shows diffuse or focal
increased echogeneity
• Endometrium is not adequately visualised
• Needs endometrial assessment
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Pipelle
• Adequacy of sampling?
• Focal versus global
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Endometrial hyperplasia
• A proliferation of endometrial glands that
may progress to, or coexist with
endometrial cancer
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Classification • Hyperplasia can be simple or complex.
Related to the gland/stroma ratio and level
of organisation
• With or without nuclear atypia
• It is the latter that confers the risk of
malignancy
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Risk of progression to malignancy
Simple hyperplasia w/o atypia 1%
Complex hyperplasia w/o atypia 3%
Simple atypical hyperplasia 8%
Complex atypical hyperplasia 29%
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Malignant progression
• Risks are not exact (poor data)
• Progession can take years
• BUT the incidence of concurrent
carcinoma amongst women with atypical
hyperplasia can range from 17-52%
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Endometrial cancer
• Most common gynae cancer in developed
world
• Incidence 12.9/100000
• Mortality 2.4/100000
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Distribution
20-34 1.5%
35-44 6.0%
45-54 19.0%
55-64 32.6%
65-74 22.6%
75-84 13.5%
>85 4.8%
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AUB aims of management
• Accurate diagnosis
• Effective therapies
• Symptomatic relief
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But also……
• Not miss a diagnosis of endometrial
hyperplasia or carcinoma
• Not miss a diagnosis of cervical carcinoma
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