VAGINAL BLEEDING
Dr. Paul Chang
March 31, 2015
OUTLINE
• Normal menstrual cycle
• Definitions
• Approach
• Pre-Menopausal AUB
• Post-Menopausal AUB
• Early Pregnancy Related bleeding (First trimester)
Differentials that I will not cover
• Trauma
• Bowel
• Neonatal, Pediatric causes
• Antepartum causes
Abnormal Uterine Bleeding
• In the absence of pregnancy…
• Affects 11-13% of reproductive age women(up to 30% according to
SOGC)
• 24% in women aged 36-40
• Women generally present for care because the amount, timing, or
other characteristics of the bleeding have changed from their
individual norm
Regulation of Menstrual Bleeding
• In the endometrial lining, rising levels of estradiol produced by the
follicles stimulate proliferative growth of epithelial and stromal
elements. The endometrium thickens and becomes rich in
progesterone receptors.
• Once the LH surges, the ovum is released, and the follicle collapses to
become the corpus luteum. The corpus luteum lasts for
approximately 10 days and produces large amounts of progesterone.
• Under the progestagenic influence, the endometrium enters the
secretory phase. Endometrial growth stops, and the stroma becomes
more compact and stable.
Regulation of Menstrual Bleeding
• If the egg is not fertilized, the corpus luteum degenerates and no
longer produces progesterone, the estrogen level decreases, the top
layers of the lining break down and are shed, and menstrual bleeding
occurs
Normal Dimensions of Menses
• Frequency of menses
• Every 24-38 days
• Regularity of menses from cycle-to-cycle
• +/- 2 to 20 days
• Heaviness of flow
• 5-80mL per month (avg 35mL)
• Duration of flow
• 4-8 days
Definitions
• Menorrhagia: menstrual periods with abnormally heavy or prolonged
bleeding (>80mL per month)
• Oligomenorrhea: cycle length > 35 days
• Polymenorrhea: cyclic length > 24 days
• Metrorrhagia: irregular intervals with normal or reduced volume and
duration of flow
• Menometrorrhagia: irregular intervals with excessive volume and
duration of flow
• Postmenopausal bleeding: bleeding that occurs more than 12 months
after the last menstrual cycle
FIGO Menstrual Disorders Working Group
2012
• Suggested new nomenclature for Abnormal Uterine Bleeding (AUB)
• Goal: Simplify
• Eliminate terminology such as menorrhagia, metrorrhaiga, and
dysfunction uterine bleeding
• Terminology for AUB
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Volume
Regularity
Frequency
Duration
Other
Menstrual History
• Age of menarche
• Volume
• Regularity
• Frequency
• Duration
• Associated symptoms: Pain, Mittelschmerz, premenstrual symptoms
Bleeding History
• Onset
• Quantity
• Pictorial blood assessment chart
• Severity
• How many pads?
• Runs down legs?
• Interfering with school, work?
• Symptomatic
• Black outs
• SOB
• Palpitations
• Timing in relationship to menses
• Other Locations:
• Teeth
• Bruising
• Hemorrhage/transfusion hx
• Associated symptoms:
• vaginal discharge or odour
• pelvic pain or pressure
Approach
History
• Menstrual History
• Bleeding History
• OB History
• Family History
• Inherited coagulation disorders
• PCOS
• Endometrial or colon cancers
• Meds including herbs
• Anticoagulants
• Antidepressants (SSRIs and
tricyclics)
• Hormonal contraceptives
• Tamoxifen
• Antipsychotics (first generation
and risperidone)
• Corticosteroids
• Herbs: gensing, chasteberry,
danshen
Physical Exam
• Vitals, weight, BMI
• Signs of anemia
• Conjunctivae Hb 95
• Hand Crease Hb 75
• Ocular Bruits Hb 55
• Signs of bleeding disorder
• Petechiae, Ecchymoses, swollen joints
• Thyroid exam
• Gyn exam (bimanual and speculum)
Investigations
• CBC
• bHCG
• Ferritin
• INR, PTT
• TSH
• Blood group and type
• vWF screen when indicated
(factor VIII, vWF antigen, vWF
functional assay)
• Pap smear and cervical cultures
when indicated
• Pelvic ultrasound/ saline infusion
ultrasound
• Endometrial biopsy
• D&C
• Hysteroscopy
Saline Infusion Ultrasound
• Sonohysterogram
• Hysterosonogram
Saline Infusion Ultrasound
Acute Management
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ABCs
Vitals
Estimate stage of shock
IV, foley, pulse oximeter, O2
Bolus 1-2L of RL or NS
Ultrasound
Group and type & bHCG
Call for help
If pregnant, remember to assess the gestation (FHR), Rhogam if
appropriate
DDx By Age
• 13-18
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Hypothalamic-Pituitary-Ovarian access immature
Hormonal contraceptives
Pregnancy
Pelvic infection
Coagulopathies
DDx By Age
• 19-39
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Pregnancy
Polyp
Leiomyoma
Anovulation (PCOS)
Hormonal contraceptives
Endometrial hyperplasia/cancer
DDx By Age
• 40 and over
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Anovulatory bleeding
Endometrial Hyperplasia
Endometrial Cancer
Vaginal atrophy
Use of anti-coagulants
Rarely leiomyoma
Medical Therapies
• NSAIDs
• Antifibrinolytics (Tranexamic Acid)
• Combined Hormonal Contraceptives
• Cyclical progestins for anovulatory bleeding
• Continous high dose progestins
• Depo medroxyprogesterone acetate
• Levonorgestrel IUD
• GnRHa
High Yield Diagnosis & Its
Management
Endometrial Polyps
• Overgrowth of cells in the lining
of the uterus (endometrium)
leads to the formation of uterine
polyps, also known as
endometrial polyps
• Menstrual characteristic:
• Intermenstrual spotting
• Hysteroscopic resection
Adenomyosis
• Endometrial tissue, which normally
lines the uterus, exists within and
grows into the muscular wall of the
uterus
• Often asymptomatic
• Menstrual characteristic:
• Heavy, prolonged periods
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Dysmenorrhea
Dyspareunia
Inter-menstrual bleeding
O/E: Enlarged uterus
• Hormonal contraceptives
• NSAIDs
• Dienogest (Visanne©)
• Mirena©
• GnRHa
• Hysterectomy
Adenomyosis
Fibroids
• Monoclonal non-cancerous growth
of the myometrium
• As many as 3 out of 4 women have
uterine fibroids sometime during
their lives
• Often asymptomatic
• Menstrual characteristic:
• Heavy prolonged periods
• U/S: bulky uterus
• Hormonal contraceptives
(*personally do not recommend)
• NSAIDs
• Tranexamic acid
• SPRMs (Fibristil©)
• Mirena©
• GnRHa
• Myomectomy
• Uterine artery embolization
• mrHIFU
• Hysterectomy
Fibroids
Fibristil©
• Ulipristal acetate
• Selective Progesterone Receptor
Modulator
Von Willebrand Disease
• Most cases are autosomal dominant
inherited disorders. Most severe form is
autosomal recessive. May be acquired
• Most common inherited bleeding
disorder
• The prevalence of vWD is about 1 in 100
individuals. However the majority of
these people do not have symptoms. The
prevalence of clinically significant cases is
1 per 10,000
• Menstrual characteristic:
• Heavy volume is more prevalent (57-93%
vs. 10% in normal controls)
• Special tests: vWF screen (factor VIII, vWF
antigen, cWF functional assay)
• Medical Management:
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OCP
Depo-Provera
Mirena
GnRHa
Tranexamic Acid
DDAVP*
Replacement therapy (Humate-P, platelets,
cryoppte, FFP)
• Surgical Management: Endometrial
Ablation
• Contraindications: NSAIDs
Anovulatory
• Most common: PCOS
• Hypothalamic hypogonadism
• Premature ovarian failure
• Menstrual characteristic:
• Irregular with variable frequency
and duration
• Hormonal contraceptives
• Cyclical progestins
Iatrogenic: Breakthrough Bleeding
• Non-menstrual bleeding while on
hormonal contraceptives
• The low dose of oestrogen in
modern contraceptive pills is
insufficient to maintain
endometrial integrity and the
opposing effect of progestogen
promotes atrophy of glands and
stroma. The resulting endometrium
is thin, fragile and prone to
bleeding
• Menstrual characteristic:
• Light and intermenstrual
• Reassurance: continue CHC for up
to 3 months
• Change to a more estrogenic CHC
• Consider vaginal ring
• Refer to Dr. Nayot’s talk
Endometrial
• AUB can occur in women with
normal ovulatory function, and
without coagulopathies because of
abnormalities that reside in the
endometrium:
• Abnormal prostaglandin synthesis
• Prostaglandin receptor
upregulation
• Increased fibrinolytic activity
• Increased tissue plasminogen
activity
• NSAIDs
• Hormonal contraceptives
• Progestins
• Mirena©
• Tranexamic acid
• SPRMs (Fibristil©)
• GnRHa
• Endometrial ablation
• Hysterectomy
Early Pregnancy
• Remember to give Rhogam if mom is Rh-ve (unless certain that of
paternity and that he is also Rh-ve)
• <12 wk GA, 120mcg IM
• 12 wks and higher, 300mcg IM
• DO NOT FORGET: Follow bHCG to zero if non-viable
Abortion
• Expectant
• Misoprostol
• D&C
Ectopic
• Send to hospital
• MTX
• Laparoscopic surgery
Molar Pregnancy
• Suction D&C
• Oxytocin during curettage
• MTX
Endometrial Hyperplasia
• Risk factors:
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Nulliparity
Late menopause
Obesity
Smoking
Anovulation (PCOS)
Unopposed estrogen
Tamoxifen
• Endometrial biopsy or D&C
• Pelvic ultrasound (≤4mm is low risk)
• Hysteroscopy
Endometrial Hyperplasia
WHO
Progression to Cancer
Simple Hyperplasia
1%
Complex Hyperplasia
3%
Atypical Simplex Hyperplasia
8%
Atypical Complex Hyperplasia
29%
• Medical Management
• Progesterone therapy
• Provera 10mg 14 days per month (x 3 months)
• Megace
• Mirena
• Clomid (SERM)
• Surgical Management: Hysterectomy
Endometrial cancer
• Most common gynecologic
cancer in North America
• Avg age for endometrial ca is 61
• 5-30% of cases occur in
premenopause
• HPNCC have a lifetime risk for
endometrial ca of 40-60%
• Refer to Gynecologic Oncologist
Summary
• Rule out pregnancy
• PALM COEIN (I = iatrogenic and infectious)
• History (menstrual, bleeding)
• Physical
• Investigations
• Acute management
• On-going therapies
• Refer if appropriate
• Read the question. Breathe. You can do it!
Thank You