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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

Estradiol
Progesterone
LH

14

28

Anovulation
LH

FSH
Estradiol
Progesterone
0

14

28

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

CAUSES

Atrophic vaginitis (most common)


Hyperplasia
Polyps
Exogenous estrogens (HRT)
Malignancy (endometrial, cervical,
vagina etc)
Other: trauma, bladder, rectum

Management

History
Clinical examination
Cytology smear
Ultrasound
Histology

Postmenopausal
bleeding
Cytology
VCE smear

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

Endometrial hyperplasia

Simple hyperplasia
without atypia
with atypia

Risk for Carcinoma

1%
8%

Complex hyperplasia
without atypia
with atypia

3%
29%

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 salpingooophorectomy 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

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